IJCCM October-December 2003 Vol 7 Issue 4 Indian J Crit Care Med October-December 2005 Vol 9 Issue 4

Review Article

Mechanical ventilation: changing concepts

Pablo Rodriguez,1 Michel Dojat,2 Laurent Brochard1
Abstract

Mechanical ventilation is routinely delivered to patients admitted in intensive care units to reduce work of
breathing, improve oxygenation, or correct respiratory acidosis. Although traditional modes of mechanical
ventilation achieve many of these goals, they have important limitations. Alternative modes are supposed
to handle some of these limitations and are now available on modern ventilators. This article reviews
general aspects of functioning and limitations of traditional modes of mechanical ventilation, and the poten-
tial interest of some new promising modes.

Key Words: Acute respiratory failure, Mechanical ventilation, Ventilator modes

Introduction is no clear consensus about when, how and at which

Mechanical ventilation is frequently delivered to pa- level patient’s work of breathing should be reduced. In-
tients admitted in intensive care units (ICU) to reduce sufficient assistance may induce diaphragmatic fatigue
work of breathing, improve oxygenation, or correct res- or weakness and force the recruitment of accessory in-
piratory acidosis. Common indications, according to a spiratory muscles, sometimes leading to respiratory aci-
multinational survey involving more than 5000 patients, dosis.[3,4] Excess in assistance may induce respiratory
are acute respiratory failure (69%), coma (17%), acute alkalosis and reduce respiratory drive, facilitating the
on chronic respiratory failure (13%), and neuromuscu- appearance of patient­ventilator asynchronies and sleep
lar disorders (2%).[1] disruptions.[2,5–7]

In most cases, ventilator is set to completely control In this article, we will review new insights in some new
patient’s ventilation shortly after intubation. The objec- promising alternative modes of ventilation aimed to im-
tive is to improve oxygenation without inducing damage prove the adaptation of the ventilator to patient’s respi-
to the lungs and to put the respiratory muscles at rest. ratory demand, including proportional assist ventilation,
Afterwards, when patient’s condition begins to improve, adaptative support ventilation, and knowledge­based
his or her ventilation is assisted by the ventilator until systems.
extubation. This can be done with all traditional modes
at variables degrees.[2] Although this seems logical, there Traditional Modes of Mechanical
Ventilation
From: Modes of ventilation summarize the way assistance is
1
Service de Réanimation Médicale, Hôpital Henri Mondor; INSERM U615,
Université Paris 12, Créteil, France
applied to patient’s respiratory system by the ventilator.
2
INSERM/UJF U594, Neuro­Imagerie Fonctionelle et Métabolique, LRC CEA They are usually defined by control and phase vari-
30V, CHU de Grenoble, France
ables.[8]
Correspondence:
Pr. Laurent Brochard, Service de Réanimation Médicale, Hôpital Henri Mondor,
51 avenue du Maréchal de Lattre de Tassigny, 94010 CRETEIL, France Control variables are flow (or volume) or pressure.

Free full text available from www.ijccm.org

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When using traditional modes, ventilators control only trigger for assisted ventilation. Thereafter, the control
one variable (flow/volume or pressure). The other one variable (flow or pressure) increases up to a predefined
(pressure or volume) reflects patient’s effort and respi- limit and is maintained at this level until the end of inspi-
ratory system mechanical properties according to the ration. In the case of flow control mode, inspiration fin-
equation of motion of the respiratory system (Figure 1). ishes after a fixed inspiratory time or after delivering a
defined volume. On the other hand, the end of inspira-
Phase variables refer to how respiratory cycle is “han- tion in pressure modes is defined by time pressure con-
dled” by the ventilator: change from expiration to inspi- trolled ventilation (PCV) or when inspiratory flow reaches
ration, inspiration, change from inspiration to expiration a predefined threshold pressure support ventilation
and expiration.[8] Inspiration starts when a signal reaches (PSV). Finally, pressure during expiration can be con-
a specific threshold value: time (set respiratory rate) in trolled until next inspiratory cycle, allowing the delivery
the case of controlled ventilation and pressure or flow of positive end expiratory pressure (PEEP).

Figure 1: The equation of motion of the respiratory system that

establishes the relationship between airway pressure (Paw), the Figure 3: Example of adaptive pressure ventilation (APV). In this
elastic (PE) and resistive (PR) components and the inspiratory case, tidal volume increases due to a larger patient’s demand (full
muscles effort (Pmus). Pappl: Total applied pressure on the arrow). APV inappropriately reduces pressure level during the next
respiratory system; PE0: elastic recoil pressure before inspiration; cycles (empty arrows). This type of response can also be seen
Vt: tidal volume; E: elastance; V: inspiratory flow; R: resistance during volume support (VS)

Figure 2: Ventilation with volume­assured pressure support Figure 4: Example of proportional assist ventilation with a high
(VAPS). The first two inspirations are pressure­targeted cycles. degree of gain (90% of flow and volume assistance). Airway
During the next two inspirations, delivered volumes are less than pressure (Paw) grossly follows esophageal pressure (Peso). Large
the desired minimum tidal volume (empty arrows) when instant Peso swings produce bigger pressure assistance (full arrow) and
inspiratory flow reaches the “constant flow level” (full arrows). At vice versa (empty arrow). This example was obtained with a Puritan
this point, the ventilator delivers a constant inspiratory flow to attain Bennett 840 (Tyco Healthcare, Mansfield, MA). This ventilator
the minimum tidal volume. Thus, an increase in airway pressure is automatically performs tele­inspiratory pauses during PAV to
observed (*) measure elastance (*)

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“Traditional” modes are frequently chosen by clinicians. flow and can be manually set in some ventilators. Stand-
According to international surveys, assist control venti- ard setting is 25% of peak inspiratory flow. Additionally,
lation (ACV), PCV, synchronized intermittent mandatory a maximal inspiratory time can be set in some ventila-
ventilation (SIMV) and PSV are largely preferred.[1,9] tors, introducing a conditional time cycling variable, simi-
lar to PCV. This may be of interest in the presence of
ACV, the most frequently used mode, allows a precise leaks, as shown during non invasive mechanical venti-
control of tidal volume and minute ventilation.[10] This is lation for avoiding prolonged inspirations and patient-
especially important during the initial phase of mechani- ventilator asynchrony.[17] Altogether, these features may
cal ventilation, when patient’s effort must be largely re- give the patient the opportunity for choosing his (or her)
duced and oxygenation needs be improved. ACV is a tidal volume, inspiratory time, and flow. This makes PSV
flow (or volume) controlled and time (or volume) cycled suitable for assisted mechanical ventilation. It has also
mode. Consequently, airway pressure is not controlled been proved to been useful for weaning.[18,19]
during inspiration, and depends on the equation of mo-
tion of the respiratory system. This is not very trouble- Several drawbacks related to its characteristics have
some during controlled ventilation, because airways been stressed for PSV, making setting not so easy as
pressures, especially plateau pressure, can be easily previously envisaged.[20] First, setting the level of pres-
monitored. sure support is still a matter of discussion. Normally, it is
set to obtain a respiratory rate within a desired interval,
Adaptation is usually facilitated by sedation at the be- a certain tidal volume and to abolish accessory muscle
ginning of mechanical ventilation. Sedation is also utilization.[16] This is furthermore complicated by the fact
needed to facilitate tolerance to particular settings such that severe and maybe unacceptable patient­ventilator
as small tidal volumes used in patient suffering from asynchronies have been reported with high level of as-
acute respiratory distress syndrome.[11,12] However, con- sistance.[2,21] Second, without intervention pressure sup-
tinuous and deep sedation has been associated with port will be always the same whatever patient’s respira-
increased duration of mechanical ventilation and length tory demand. This prompts to a frequent need for re-
of stay in the ICU.[13] evaluations of the patient’s and monitoring of alveolar
ventilation (minute ventilation and PaCO2). Third, pres-
Fixed settings of inspiratory time, flow, and tidal vol- sure rise time is also important. Low pressurization rates
ume during assisted ventilation with ACV can be very increase patient’s effort, whereas very high rates may
difficult to tolerate for patients having a high respiratory induce cough and are frequently experienced as uncom-
drive. For example, early auto­triggering (double cycling) fortable.[22] Finally, cycling off criteria (also called expira-
may happen if patient’s inspiratory time is larger than tory trigger) may also play a role in terms of patient-
ventilator time.[14] Insufficient flow during ACV may be ventilator interaction.[14] As previously stated, some ven-
perceived as a resistance to inflow by the patient and tilators allow changing the cycling off criteria. Although
increases patient’s effort.[15] it is not still clear which flow value must be used, some
ventilator only propose fixed algorithms that may in-
Pressure­targeted modes, such as PSV, can overcome crease the risk of delayed cycling (e.g., 5 l/min for Puri-
some of the limitations observed during ACV. PSV is a tan Bennett 7200 [Tyco Healthcare, Mansfield, MA] and
patient­initiated, pressure controlled and flow cycled 5% for Siemens 300 [Siemens Medical Systems Inc,
mode.[16] This means that pressure assistance is con- Lund, Sweden]).[16] Different criteria may be needed in
stant whatever patient’s effort is and proportional to the patients showing a high respiratory drive and shorter
level of pressure support.[2] Inspiratory flow is variable neural inspiratory times, such as patients with obstruc-
and decelerating. It depends on patient’s effort and on tive lung disease.[14] Additionally, these patients may
his (or her) respiratory mechanics (airway resistance and show recruitment of expiratory muscle during late ven-
respiratory system elastance). Cycling off criteria (from tilator inspiration.[23] This may further promote an in-
inspiration to expiration) is usually reached when inspira- crease in dynamic intrinsic PEEP and, as a conse-
tory flow attains a predefined threshold. This value is quence, may decrease the likelihood to recognize next
usually expressed as a percentage of peak inspiratory patient’s effort.[24]

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Improving Patient and Ventilator Matching flow” level. Inspiration can be triggered by time (control-
“Alternative” modes were developed to improve match- led cycle) or by the patient. At the beginning, the venti-
ing between patient’s ventilation demand and ventilator lator delivers gas to increase airway pressure, behaving
supply. In the vast majority, they are modification of “tra- as in PCV or PSV. As in pressure controlled modes,
ditional” modes, which take advantage of ventilator mi- flow decreases progressively until a predefined level
croprocessor to adapt assistance to reach specific ob- (“constant flow”). At this point, if inspiratory tidal volume
jectives. This can represent different levels of complex- is equal or greater than predefined minimum tidal vol-
ity, from just assuring a predefined minute ventilation or ume, then inspiratory valve closes and expiration be-
tidal volume to a complex adaptation of assistance ac- gins as in PSV. However, if inspiratory tidal volume is
cording to respiratory pattern or physiological variables. smaller, then inspiration will continue with a constant
In the next paragraph, we discuss the interest, clinical flow until the minimum tidal volume is delivered without
evaluation, and limitation of alternative modes aimed to further pressure control.[25,26] This may dangerously in-
improve the interaction between patient and assistance crease inspiratory time, predisposing the patient to gas
delivered by the ventilator. trapping (intrinsic PEEP) and phase asynchronies when
patient’s effort is reduced (Figure 2). Although one short
Dual-control Modes term physiological study showed improvements in work
Ventilator controls only one variable (pressure or vol- of breathing and synchronisation compared with ACV,[26]
ume/flow) during assistance with traditional modes such there are no data about long term utilisation of this mode.
as PSV or ACV. Some ventilators also offer special Volume support adjusts pressure support to attain a
modes that allow controlling both variables. However, predetermined tidal volume and while maintaining minute
there is only one single variable (pressure or volume/ ventilation in a breath­to­breath basis. It was originally
flow) that is actually controlled at a given part of inspira- included in Servo 300 (Siemens Medical Systems Inc,
tion. This kind of modalities is frequently enclosed un- Lund, Sweden) and is actually available in Servo i
der the term “dual­control” modes. Nomenclature is het- (Maquet Inc, Solna, Sweden). It is an assisted, pres-
erogeneous, changes from ventilator to ventilator and sure controlled and flow cycled mode as PSV. Specific
sometimes is not very informative.[25] settings are desired tidal volume and respiratory rate.
Initially, ventilator calculates patient’s dynamic compli-
Dual­control modes can be seen as basic algorithm ance during a test breath with 5 cm H2O of pressure
based closed­loop modes. In almost all cases, airway support. Thereafter based on this “constant,” it calcu-
pressure is the controlled variable, which is adjusted to lates the pressure needed to produce set tidal volume.
attain a specific tidal volume. This can be done within Changes cycle to cycle can be less than 3 cm H2O, go-
one single inspiration or in a breath­to­breath fashion. ing from PEEP to 5 cm H2O below maximal peak in-
The objective is simple: better adaptation to changes in spiratory pressure. Another rule can increase target tidal
respiratory mechanics in case of assisted ventilation, and volume when patient’s respiratory rate is less than set
control of airway pressure while assuring minute venti- respiratory rate to keep minimum minute ventilation con-
lation. Potentially, this can improve patient’s comfort and stant. Volume support “correctly” increases assistance
reduce the necessity of frequent modification in ventila- when tidal volume is reduced, as can be observed in
tor settings. However, as we will below, basic dual­con- patients with increasing airway resistance or rapid shal-
trol modes present several problems sometimes putting low breathing. If, however, the patient increases his or
patients at risk. Additionally, published clinical experi- her effort (and tidal volume) to compensate an incre-
ence with these modes is scarce. ment in respiratory demand as can be seen in fever or
acidosis, it will paradoxically decrease assistance (Fig-
Volume­assured pressure support (VAPS) is an ex- ure 3). The latter has been recently showed in a physi-
ample of dual mode, which adapts within one cycle. It ological study conducted in patients exposed to in-
has been described more than 10 years ago and has creases in dead space.[27]
been included in Bird 8400 and T­Bird (Bird Corp, Palm
Springs, CA).[26] Specific settings are minimum tidal vol- Some pressure controlled and time cycle modes have
ume, respiratory rate, pressure support and “constant been introduced by manufacturers. They share many

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characteristics of volume support. Some examples are allowing a greater variability of tidal volume with differ-
pressure­regulated volume control (PRVC) available in ent degrees of assistance.[36,37] Additionally, PAV may
Servo ventilators, Adaptive Pressure Ventilation from significantly improve patient­ventilator matching com-
Galileo (Hamilton Medical AG, Bonaduz, Switzerland) pared with traditional modes of mechanical ventilation[38]
and Autoflow from Evita 4 (Dräger, Lübeck, Germany). and may increase comfort.[39,40] Some investigators have
They just adjust airway pressure to attain specific target evaluated the utility of PAV over prolonged periods dur-
tidal volume and minute ventilation. As in volume sup- ing non invasive mechanical ventilation: no major side
port, when faced with increases in patient respiratory effect was noted and data suggested that it might be
effort that may increase tidal volume, the ventilator will better tolerated.[40–43] Less refusals to continue mask
actually reduce assistance (Figure 3). Similarly to the assistance were observed with PAV in a randomized
other dual­control modes, published experience is very study.[40]
limited.[28,29]
Several drawbacks have been signaled for PAV. As it
Proportional Assist Ventilation was previously described, elastance and resistance must
Proportional assist ventilation (PAV) is conceptually be known by the ventilator to work correctly. This may
different from all available modes of mechanical ventila- be difficult during assisted ventilation. If incorrect high
tion. It is a patient­triggered and pressure­controlled values are introduced and high percentage of assistance
mode which adapts assistance according to patient’s is used, the ventilator can overassist the patient and fail
effort and mechanics properties within the inspiratory to recognize the end of patient breath. This situation is
cycle [Figure 4]. In contrast with previously cited modes known as “runaway.” Under these circumstances, the
of ventilation, PAV controlled variable (pressure) is ventilator inspiration finishes when peak pressure alarm
changed all around the inspiratory phase following in- is attained or when patient expiratory effort is strong
spiratory flow and volume instantaneous values.[30–32] enough to correct the mistake.[32] Although runaways may
PAV is based on the equation of motion of the respira- not jeopardize patients if alarms are correctly set, it may
tory system (Figure 1). As can be inferred from this for- create major phase asynchronies and discomfort. To
mula, at each moment of inspiration, total applied pres- overcome this problem, elastance and resistance can
sure on the respiratory system is equal to elastic pres- be calculated during flow controlled ventilation obtained
sure plus resistive pressure. These two components can with hyperventilation or brief sedation.[44] Another possi-
be calculated by multiplying elastance by flow and re- bility is progressively increasing volume and flow assist-
sistance by volume, respectively. Total applied pressure ance (gain) until obtaining a runaway. This allows rec-
is also equal to airway pressure (ventilator assistance) ognizing the maximum tolerable values. This is frequently
plus muscular pressure (patient’s effort). During PAV, reported as the runaway method.[32,45] However, these
ventilator calculates the applied pressure by measuring methods are not dynamic and if used, repeated meas-
its elastic and resistive components at each moment urement should be performed. Recently, new methods
while knowing instant delivered volume and flow. Then of non invasive intermittent measurements of elastance
it adjusts the pressure according to a percentage of these and inspiratory resistance during PAV have been pro-
components, usually called volume and flow assistance. posed (Figure 4).[46,47] These methods are very promis-
Thus, according to the equation of motion, the ventilator ing and have been partially integrated in PAV offered by
will pressurize airway in proportion to muscular effort, Puritan Bennett 840 (Tyco Healthcare, Mansfield, MA).
provided that the other part of applied pressure is done However, larger long­term experience is needed to test
by the patient.[32,33] If settings are correct, the ventilator its safety and efficiency.
will cycle from inspiration to expiration at the same time
that patient’s effort finishes. PAV is also affected by intrinsic PEEP, even if inspira-
tory trigger is set at the minimum value. The latter may
Several physiological studies showed that PAV effi- induce ineffective efforts or reduce the total amount of
ciently decreases respiratory effort.[31,33–35] It may also patient’s effort that is actually assisted, failing to cor-
preserve physiological breathing pattern better than PSV, rectly coupling patient inspiration to ventilator assistance.

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Ventilatory Assist Driven by the Patient tient’s body weight.

Coupling ventilator assistance to diaphragm function
is not a new idea.[48] The main interest is to avoid uncou- When starting ventilation in ASV, the ventilator pro-
pling due to mechanical factors such as intrinsic PEEP. vides three pressure control time cycle inspirations, and
calculates respiratory mechanics. Expiratory time con-
Recently, some authors have proposed modes that stant is estimated from the tidal volume curve during
assist in proportion to indicators of diaphragmatic activ- each expiration.[55] Then, using Otis’s formula, a target
ity. One approach using transdiaphragmatic pressure as respiratory rate is calculated. Target tidal volume is com-
driven signal was tested in healthy subjects exposed to puted from minimum minute ventilation and target res-
different levels of inspiratory pCO2. The ventilator was piratory rate. Thereafter, target values are calculated
well synchronized to subjects’ efforts.[49] Although this cycle by cycle. Depending on patient’s spontaneous res-
mode may appear promising, transdiaphragmatic pres- piratory rate, ASV can works as PCV, if there is no spon-
sure signal sometimes is altered by cardiac artifacts or taneous breathing; as pressure SIMV, when patient’s
expiratory muscle interference possibly limiting its util- respiratory rate is smaller than target; or as PSV, if pa-
ity.[50] Another interesting approach is neurally adjusted tient’s respiratory rate is greater. Pressure level is then
ventilatory assist (NAVA).[51] It is a promising but still adapted to attain the target tidal volume (within limits
experimental mode of ventilation. It provides assistance imposed by pressure alarms). Cycling off criteria is flow
in proportion to diaphragm effort. It depends on continu- based in the case of assisted ventilation or time based
ous recording of diaphragmatic electrical activity, which for mandatory inspiration.[53]
is obtained via a nasogastric catheter incorporating a
multiple array esophageal electrode (nine electrodes There is not much published experience with ASV.
spaced 10 mm apart). The onset and end of assistance Most studies are short term and during the postopera-
and the level of assistance are directly driven by this tive period.[56–60] All these studies showed promising
signal.[52] In theory, NAVA should provide better patient- results, including decrease of patient’s respiratory ef-
ventilator synchrony than other pressure­targeted forts, stability of alveolar ventilation without operator’s
modes. First results support this expectation. Unlike all intervention and safety during weaning in selected situ-
other modes (including PAV), NAVA should not be influ- ations. However, many important unsolved questions
enced by intrinsic PEEP or by the presence of leaks as remain to be answered for ASV: how minimum ventila-
in the case of standard triggering systems. The initial tion must be set, how ASV must be adapted faced with
report on NAVA revealed advantages compared with changes in breathing demand and how weaning must
PSV in terms of triggering and cycling­off synchrony.[52] be handled.
These first physiological results are encouraging.
Knowledge-based Systems
Adaptive Support Ventilation When the physiological and clinical knowledge needed
Adaptive support ventilation (ASV) is a pressure con- to manage a well defined clinical situation is acquired, it
trolled closed­loop system which allows adaptation of can be embedded within a computer program that drives
assistance during all phases of mechanical ventilation, the ventilator using artificial intelligence techniques, such
from control ventilation to weaning.[53] It is only devel- as production rules, fuzzy logic, or neural networks.[61]
oped in Hamilton ventilators (Hamilton Medical AG, These new techniques allow planning and control. Con-
Bonaduz, Switzerland). The main principle of function- trol is a local task, which consists of determining what
ing is based on Otis’s formula.[54] Using this formula, the the immediate next step is. Planning is a strategic task,
microprocessor can calculate an “ideal” respiratory pat- aimed at regulating the time­course of the process. For
tern (tidal volume and respiratory rate), which needs the control and planning, numerous techniques have been
smallest total energy expenditure, providing specific developed in the fields of control theory and artificial in-
minute ventilation, a calculated dead space, which de- telligence, respectively. The main difference between
pends on body weight and an expiratory time constant. these two fields lies in the process models used. Con-
Minimum minute ventilation is the only specific setting trol and planning are two complementary and essential
that must be chosen by the clinician. It is based on pa- tasks that must be combined to design multi­level con-

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IJCCM October-December 2003 Vol 7 Issue 4 Indian J Crit Care Med October-December 2005 Vol 9 Issue 4

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Conclusion 11. The Acute Respiratory Distress Syndrome Network, Ventilation
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