Table of modes of mechanical ventilation

In medicine, mechanical ventilation is a method to mechanically assist or replace spontaneous breathing. For this purpose, medical devices called Ventilators are used. Modern Ventilators offer a number of methods to deliver the breaths to the patient. These methods are called Modes of mechanical ventilation^[1] (Mode) and are selected by the clinician.

Common to all modes is that they allow the clinician to control

Composition of gas mixture delivered (Setting: fraction of inspired oxygen, FiO2)
Pressure at the end of exhalation (Setting: Positive End-Expiratory Pressure PEEP)

However, they differ in the way to deliver breaths^[2].

Breath delivery follows the phases of breathing,^[3] i.e., inhalation and exhalation:

Inhalation:
- Start of inhalation is defined by the Trigger:
- Delivery of gas mixture is defined by the Inhalation Mechanism.
Exhalation:
- Cycling from inhalation to exhalation is defined by the Cycling mechanism.
- Time for exhalation is defined by the Exhalation Mechanism.

CAVEAT: Although manufacturers may offer identical breath delivery methods, the names of the Modes may be different.

Trigger: The ventilator needs to know when to start delivering gas to the patient. If the patient does not breathe at all, a timer starts inhalation. If the patient has some breathing activity, the ventilator can sense this effort by measuring pressure or flow and start inhalation if pressure or flow drop below a certain threshold. That threshold is called Trigger Sensitivity.

Inhalation Mechanism: Technically, two methods to deliver the gas mixture can be employed, flow controlled or pressure controlled. Flow control means that the ventilator outputs a pre-set flow and maintains that flow until the end of inhalation. Pressure control means that the ventilator outputs a pre-set pressure and maintains that pressure until the end of inhalation. Both methods have their advantages and disadvantages. Flow control will deliver the gas mixture independent of resistance to flow and guarantee a set delivery of gas. In the process, pressure might become very high and potentially dangerous to the patient. Pressure control will deliver the gas mixture at a pre-set level and never exceed that pressure. However, it may not succeed to deliver a set volume of gas mixture.

Cycling mechanism: Inhalation must eventually stop and enable to lungs to exhale. If the patient does not breathe, the ventilator must switch to exhalation after a pre-set time or after a pre-set volume has been delivered. If the patient has some breathing activity left, the ventilator can sense this by measuring flow and start exhalation, for example if flow drops below a certain threshold. That threshold may be termed "Expiratory Trigger Sensitivity".

Exhalation Mechanism: Exhalation requires time for the lungs to empty. This time starts with the onset of exhalation and ends with the start of the subsequent inhalation. If the patient is passive, the exhalation is terminated by a timer. If the patient has some breathing activity, exhalation is terminated by the subsequent inhalation effort of the patient.

The table below lists the working principles of some of the common modes of ventilation. (Vent = controlled by ventilator; Pat = controlled by patient, based on flow or pressure measurent)^[4].

Some modes offer a special convenience feature, called Servo. For example: When Pressure Vontrolled Ventilation (PCV) is used, the volume delivered by the Ventilator may vary depending on the patient's lungs and the patient's efforts. Hypothetically, a clinician may sit next to the Ventilator and adjust the pressure control knob breath-by-breath to maintain a certain target volume. In Servo mode, the clinician inputs the target volume and the Ventilator adjusts the pressure control knob breath-by-breath.

Mode examples, not exhaustive!	Trigger	Inhalation Mechanism	Cycle	Exhalation Mechanism	Servo
Volume Controlled Ventilation, CMV, VCV, AC)	Vent or Pat	Flow	Vent	Vent	no
Pressure Controlled Ventilation PCV	Vent or Pat	Pressure	Vent	Vent	no
Synchronized Intermittent Mandatory Ventilation SIMV (volume cycled)	Vent or Pat	Flow	Vent or Pat	Vent	no
Synchronized Intermittent Mandatory Ventilation SIMV (pressure limited)	Vent or Pat	Pressure	Vent or Pat	Vent	no
Synchronized Intermittent Mandatory Ventilation plus Pressure Support, SIMV+P_S (volume cycled)	Vent or Pat	Flow	Vent or Pat	Vent	no
Synchronized Intermittent Mandatory Ventilation plus Pressure Support,SIMV+P_S (pressure limited)	Vent or Pat	Pressure	Vent or Pat	Vent	no
Continuous Positive Airway Pressure CPAP	Pat	Pressure	Pat	-	no
Continuous Positive Airway Pressure plus Pressure Support CPAP+P_S	Pat	Pressure	Pat	Pat	no
Airway Pressure Release Ventilation, APRV, two level CPAP	Vent or Pat	Pressure	Vent or Pat	Vent	no
Inversed Ratio Ventilation (usually PCV based)	Vent or Pat	Pressure	Vent	Vent	no
Volume Support^[4]	Pat	Pressure	Pat	Pat	Yes (Volume target)
Proportional Assist Ventilation PAV^[4]	Pat	Pressure	Pat	Pat	Yes (Pressure proportional to elastic load)
Nerually Adjusted Ventilation Assist NAVA^[4]	Pat	Pressure	Pat	Pat	Yes (Pressure proportional to measured patient effort)

References

^ Cairo, J.M. (2020). Pilbeam's Mechanical Ventilation. Physiological and clinical applications. St. Louis, Missouri: Elsevier. pp. 62ff. ISBN 978-0-323-87164-8.
^ Esteban A, Alía I, Ibañez J, Benito S, Tobin MJ (1994). "Modes of mechanical ventilation and weaning. A national survey of Spanish hospitals. The Spanish Lung Failure Collaborative Group". Chest. 106 (4): 1188–93. doi:10.1378/chest.106.4.1188. PMID 7924494.
^ Brunner, J.; Wolff, G.; Langenstein, H.; Cumming, G. (December 1985). "Reliable detection of inspiration and expiration by computer". International Journal of Clinical Monitoring and Computing. 1 (4): 221–226. doi:10.1007/BF01720186. ISSN 0167-9945.
^ ^a ^b ^c ^d Navalesi P, Costa R (2003). "New modes of mechanical ventilation: proportional assist ventilation, neurally adjusted ventilatory assist, and fractal ventilation". Curr Opin Crit Care. 9 (1): 51–8. doi:10.1097/00075198-200302000-00010. PMID 12548030.

[:0-1] Cairo, J.M. (2020). Pilbeam's Mechanical Ventilation. Physiological and clinical applications. St. Louis, Missouri: Elsevier. pp. 62ff. ISBN 978-0-323-87164-8.

[pmid7924494-2] Esteban A, Alía I, Ibañez J, Benito S, Tobin MJ (1994). "Modes of mechanical ventilation and weaning. A national survey of Spanish hospitals. The Spanish Lung Failure Collaborative Group". Chest. 106 (4): 1188–93. doi:10.1378/chest.106.4.1188. PMID 7924494.

[3] Brunner, J.; Wolff, G.; Langenstein, H.; Cumming, G. (December 1985). "Reliable detection of inspiration and expiration by computer". International Journal of Clinical Monitoring and Computing. 1 (4): 221–226. doi:10.1007/BF01720186. ISSN 0167-9945.

[pmid12548030-4] Navalesi P, Costa R (2003). "New modes of mechanical ventilation: proportional assist ventilation, neurally adjusted ventilatory assist, and fractal ventilation". Curr Opin Crit Care. 9 (1): 51–8. doi:10.1097/00075198-200302000-00010. PMID 12548030.

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Table of modes of mechanical ventilation

See also

References

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