D e s i g n F e a t u re s o f

Modern Mechanical
Ventilators
Neil R. MacIntyre, MD

KEYWORDS
 Mechanical ventilation  Modes of ventilation  Patient–ventilator interactions
 Ventilator-induced lung injury  Closed-loop control

KEY POINTS
 Mechanical ventilator design features can be challenging to understand because of imprecise and
confusing terminology.
 Mechanical ventilator design features have evolved, reflecting new awareness of ventilator-induced
lung injury and patient–ventilator synchrony.
 As newer designs are introduced, clinical adoption will require outcome data to support their use.

INTRODUCTION (volume or pressure controlled). Now the term

is often used to distinguish a machine-triggered
Positive pressure mechanical ventilators have breath from a patient-triggered breath (assist
evolved over the last several decades from simple control). This article will generally avoid the
high pressure gas regulators to sophisticated mandatory/spontaneous terminology and use the
microprocessor systems controlling many aspects terms assist and control to mean a patient- and
of breath delivery, inspiratory/expiratory timing, machine-triggered breath.
and expiratory pressure.1 Terminology describing
these operations has also evolved and often
BASIC CONCEPTS
has become confusing. Some of this confusion
Breath Delivery Algorithms
is a consequence of manufacturer’s trade names
describing a common design feature in multiple Although the engineering principles underlying pos-
proprietary terms. Another problem has been itive pressure breath delivery can be complicated,2,3
that simple older terminology is unable to fully from a clinical perspective, a mechanical breath can
describe many of the advances that have be classified in terms of what initiates the breath
occurred. Two examples are the mandatory (trigger variable), what controls gas delivery during
versus spontaneous breath classification and the breath (target or limit variable), and what termi-
the concepts underlying controlled versus assis- nates the breath (cycle variable).4
ted ventilation. The terms mandatory versus In general, breaths can be initiated (triggered)
spontaneous originally meant machine alone by patient effort (assisted breaths) or by the ma-
versus patient alone. Today things are blurred as chine timer (controlled breaths). Effort sensors
patients can trigger breaths (spontaneous feature) are generally either pressure or flow sensors and
with substantial ventilator support supplied are defined by their sensitivity/responsiveness.
(mandatory feature). The term control originally Target or limit variables are generally either a set
chestmed.theclinics.com

meant parameters that the ventilator manipulated flow or a set inspiratory pressure. With flow

Disclosure: Dr N.R. MacIntyre is a consultant at Breathe Technology and Ventec.

Department of Medicine, Duke University Medical Center, Duke University Hospital, Erwin Road, Box 3911,
Room 1120, Durham, NC 27710, USA
E-mail address: [email protected]

Clin Chest Med 37 (2016) 607–613

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608 MacIntyre

targeting, the ventilator adjusts pressure to main- ventilatory support. The mode controller is an elec-
tain a clinician-determined flow magnitude and tronic, pneumatic, or microprocessor-based sys-
pattern (sine, square, accelerating, decelerating); tem designed to provide the proper combination
with pressure targeting, the ventilator adjusts of breaths according to set algorithms and feed-
flow to maintain a clinician-determined inspiratory back data (conditional variables). The 5 most com-
pressure. Modern systems also usually allow mon modes are volume assist control (VACV),
adjustment of the rate of pressure rise in pressure pressure assist control (PACV), volume synchro-
targeting. Cycle variables are generally a set vol- nized intermittent mandatory ventilation (V-SIMV),
ume, a set inspiratory time, or a set reduction in pressure synchronized intermittent mandatory
inspiratory flow as the lung fills. This flow-cycling ventilation (P-SIMV), and stand-alone pressure
criterion is manufacturer-specific (eg, 25%–35% support ventilation (PSV) (Table 1).4 Examples of
of peak flow), or it can be clinician-adjusted on proprietary names for these basic modes are given
many newer machines. A secondary cycling in Table 2. Depending upon the set control breath
mechanism may be present on some devices if rate, VACV and PACV can range from totally ma-
inspiratory time exceeds a certain fraction chine controlled to totally patient assisted. V-
(eg, 80%) of a set total cycle time. Breaths can SIMV and P-SIMV can provide VA and VC or PA
also be cycled off if pressure limits are exceeded. and PC breaths respectively interspersed with
With this approach, breath delivery algorithms either unsupported or pressure supported (PS)
from modern mechanical ventilators can be breaths. Data from international surveys5 indicate
broken into 5 basic breaths: volume control (VC), that the most commonly used mode worldwide is
volume assist (VA), pressure control (PC), pressure volume assist control, with pressure assist control
assist (PA), and pressure support (PS) (Fig. 1).4 a distant second. IMV modes have been steadily
decreasing in use, while stand-alone PSV modes
have been increasing in use.
Basic Modes of Ventilatory Support
Choice of mode depends upon the clinical goals
The availability and delivery logic of different and an understanding of ventilator breath design
breath types define the mode of mechanical features.4 Mandatory breath rates are set

Fig. 1. The 5 basic breaths defined by trigger, target, and cycle variables. Depicted are airway pressure, flow, and
volume tracings over time. Solid lines reflect set changes; dotted lines reflect variable changes from effort or me-
chanics changes. The five basic breaths. Volume control is machine triggered, flow targeted, and volume cycled.
Volume assist is patient triggered, flow targeted, and volume cycled. Pressure control is machine triggered, pres-
sure targeted, and time cycled. Pressure assist is patient triggered, pressure targeted, and time cycled. Pressure
support is patient triggered, pressure targeted, and flow cycled. (From MacIntyre NR. Principles of mechanical
ventilation. In: Broaddus VC, editor. Murray and Nadel’s textbook of respiratory medicine, 6th edition.
New York: Elsevier; 2016. p. 1762; with permission.)

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 Design Features of Modern Mechanical Ventilators 609

Table 1
that dedicated APRV modes on most devices
The 5 basic modes defined by the breaths have the set inspiratory pressure referenced to at-
available mospheric pressure rather than the set expiratory
pressure. Proponents of APRV argue that the
Breath Types Available long I:E ratio raises mean Paw without additional
set positive end expiratory pressure (PEEP) or tidal
Mode VC VA PC PA PS Sp
volume (VT) and that the spontaneous efforts dur-
Volume assist control X X – – – – ing the inflation phase enhance gas mixing and
Pressure assist control – – X X – – cardiac filling.7,8 Examples of proprietary names
Volume SIMV X X – – X X are given in Table 2.
Pressure SIMV – – X X X X
Positive End Expiratory Pressure
Pressure support – – – – X –
PEEP can be generated in 2 basic ways: applied or
The breaths are the 5 breaths depicted in Fig. 1 plus an un-
assisted spontaneous breath (Sp). Note that the clinician- intrinsic. Applied PEEP is clinician set and is usu-
set breath rate can result in VACV and PACV being totally ally provided by valving systems in the expiratory
controlled ventilation (high set rate), virtually totally assis- limb. Modern ventilators also can adjust circuit
ted ventilation (very low or absent set rate), or assist con- flow during exhalation to assure PEEP mainte-
trol ventilation (intermediate set rate).
Abbreviations: PA, pressure assist; PC, pressure control;
nance in the setting of circuit leaks. Intrinsic
PS, pressure support; VA, volume assist; VC, volume control. PEEP develops in the setting of high minute venti-
From MacIntyre NR. Principles of mechanical ventila- lation, short expiratory times, and high airway
tion. In: Broaddus VC, editor. Murray and Nadel’s text- resistance/high compliance lung units. Impor-
book of respiratory medicine, 6th edition. New York: tantly, applied PEEP distributes evenly throughout
Elsevier; 2016. p. 1762; with permission.
the lung while intrinsic PEEP is highest in high
resistance/high compliance lung units and lowest
depending upon the reliability of the patient’s effort in low compliance/low resistance units.9 Conven-
to supply an appropriate number of breaths. Pres- tional approaches to PEEP generally rely on set
sure versus flow/volume targeting balances the PEEP and avoidance of intrinsic PEEP. However,
synchrony enhancement of pressure targeting proponents of APRV argue for the use of intrinsic
against the volume guarantee of flow/volume tar- PEEP to maximize expiratory flow and minimize
geting.6 When using patient-triggered pressure- expiratory time.
targeted breaths, cycling on time (PA breaths)
versus flow (PS breaths) depends on patient com- FEEDBACK CONTROL FEATURES
fort/synchrony.
Airway pressure release ventilation (APRV) is As mechanical ventilators have evolved, so has the
often touted as a new mode but in fact is simply capability for microprocessor-based systems to
a variant of P-SIMV, in which the inspiratory time monitor conditional variables and use this informa-
is set longer than the expiratory time. Patient ef- tion to automatically adjust timing, flow, pressure,
forts thus occur during the inflation phase and and even FiO2 (feedback control). An early example
can produce additional unassisted or PS breaths. was the use of a patient effort sensor (conditional
A point of confusion exists in setting up APRV in variable) to adjust the number of mechanical

Table 2
Examples of proprietary names for the 5 basic modes and 2 feedback features

PB840 Avea/Vela Servo I G5 Evita V500

VACV A/C (VC) VAC VC (S) CMV VC-AC
PACV A/C (PC) PAC PC P-CMV PC-AC
VSIMV SIMV (VC) VSIMV SIMV (VC) SIMV VC-SIMV
PSIMV SIMV (PC) PSIMV SIMV (PC) P-SIMV PC-SIMV
PSV SPONT (PS) CPAP/PSV PS/CPAP SPONT PC-PSV
PRVC VC1 PRVC PRVC APV VC-AC (Autoflow)
PC-AC (VG)
APRV BiLevel BiPhasic Bi-Vent APRV PC-APRV
Courtesy of Medtronics PB840, Carlsbad (CA); CareFusion Avea/Vela, Yorba Linda (CA); Maquet Servo I, Solna, Sweden;
Hamilton G5, Reno (NV); Draeger Evita, Telford (PA).

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610 MacIntyre

breaths provided during either assist control 2 breath types depending on the number of patient
modes or SIMV.10 A variation on this breath rate efforts. The maximum pressure change from
feedback mechanism was mandatory (or mini- breath to breath on most systems generally is
mum) minute ventilation, which used minute venti- limited to a few centimeters of water to prevent
lation to adjust the number of positive pressure large swings in pressure and volume.
breaths delivered.11 Currently available systems These modes have been assessed clinically in 2
to partially close the loop will be described.12,13 settings. First, in severe parenchymal lung injury
(eg, ARDS [acute respiratory distress syndrome]),
Inspiratory Pressure and Flow Adjustments PRVC has been used as a way to provide more syn-
Based on Artificial Airway Geometry chronous pressure-targeted breaths while assuring
that safe tidal volume delivery is maintained. One
The endotracheal tube (ETT) imposes a significant
study demonstrated that this was possible, although
inspiratory resistance on a spontaneously breath-
a minority of patients had significant periods of time
ing patient.14 This imposed load can have an
with excess VT.19 Second, VS has been touted as a
impact on flow synchrony during interactive assis-
means to automatically wean patients, the theory
ted/supported breaths and can make it difficult to
being that as patients recover, they will make stron-
assess potential for ventilator withdrawal during
ger inspiratory efforts, and VS will automatically
periods of unassisted/unsupported breathing.
reduce inspiratory pressure. Conversely, inspiratory
Low-level (eg, 5–8 cmH2O) PS has been pro-
pressure would increase if patient effort diminished
posed as a way of eliminating the ETT resistive
or respiratory system mechanics worsened.
load.15 However, the PS algorithm supplies a con-
Whether this approach is superior to routine sponta-
stant inspiratory pressure, which, because of the
neous breathing trials (SBTs) is unclear.
high fixed resistance of the ETT, tends to under-
One must also be cautious in using VS in this
compensate the load at the beginning of the
weaning setting, because if the clinician set volume
breath. Patient muscle unloading thus is uneven
is excessive for patient demand, a patient may not
and may be suboptimal.
attempt to take over the work of breathing for that
To better address this loading pattern, many
volume, and thus support reduction and weaning
ventilators have the capability to calculate the
may not progress. In addition, if the pressure level
ETT resistance properties based on clinician input
increases in an attempt to maintain an inappropri-
of ETT length and diameter. The ventilator incorpo-
ately high set tidal volume in the patient with airflow
rates this calculation with measurements of instan-
obstruction, intrinsic PEEP (PEEPi) may result. VS
taneous flow to apply pressure proportional
may also inappropriately lower inspiratory pressure
to resistance throughout the total respiratory cy-
in a patient with excessive flow demands induced
cle.16,17 It must be recognized that the ETT
by pain, anxiety, or acidosis.20
compensation strategy is based on the input ge-
ometry of the artificial airway and cannot account
for changes in tube characteristics induced by Enhanced Feedback Control of Combination
kinks or partial occlusions or the relationship of Pressure- and Flow-Targeted Breaths
the tube opening against the tracheal wall.
Airway occlusion pressure (P0.1),21 oxygen satura-
tion (SpO2 ),22 and end-tidal CO2 concentrations23,24
Feedback Control of Combination Pressure-
have been incorporated into the pressure flow/vol-
and Flow-Targeted Breaths
ume hybrid breaths described. The one system that
Over the last 2 decades, several engineering inno- is commercially available uses end-tidal CO2 and
vations have attempted to combine the flow syn- respiratory rate along with the tidal volume to adjust
chrony advantages of pressure-targeted breaths the applied inspiratory pressure (SmartCare,
with the volume guarantee features of flow/volume Dragerwerk AG, Lubeck, Germany).24 The system
targeted breaths. The most common approach attempts to find an inspiratory pressure that main-
uses standard pressure-targeted breaths with the tains the respiratory rate and tidal volume in a
ventilator adjusting the pressure target according clinician-set comfort zone. The end-tidal CO2
to a clinician-set VT.18 When these breaths are serves as a backup signal to assure adequate venti-
exclusively supplied with time cycling, the mode lation is occurring. Inspiratory pressure is reduced
is commonly referred to as pressure-regulated vol- to as low a level as possible within these bound-
ume control (PRVC) but has a number of proprie- aries; then the clinician should be alerted to perform
tary names (see Table 2). When these breaths an SBT when this pressure reaches 9 cm H2O.
are supplied exclusively with flow cycling, the Although clinical trials have failed to consistently
mode is commonly referred to as volume support show an advantage to this approach,25,26 an auto-
(VS). Some ventilators will switch between these mated system that is just as good as clinicians

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 Design Features of Modern Mechanical Ventilators 611

could have applications in settings with rapidly MODES DRIVEN BY NOVEL SENSORS OF
recovering patients or low availability of clinicians PATIENT EFFORT
to make frequent assessments.
Two new modes have been introduced over the
Feedback Control of Ventilator Breath last 2 decades that use unique feedback control
Delivery Based on Respiratory System based on patient effort to control positive pressure
Mechanics breath delivery.13,33 The first is proportional assist
ventilation (PAV), an approach that applies a
A novel approach to automated feedback control of clinician set pressure and flow gain on patient-
ventilator support controls a pressure-targeted generated flow and volume.34 PAV uses intermit-
breath using a VT, frequency and inspiratory-to- tent controlled test breaths to calculate resistance
expiratory (I:E) ratio algorithm based on respiratory and compliance. It can then use measured flow
system mechanics. Known as adaptive lung venti- and volume to calculate both resistive and elastic
lation or adaptive support ventilation (ASV),27–30 work. The clinician is required to set a desired pro-
the system calculates respiratory system me- portion of the total work that should be performed
chanics using several controlled test breaths. It by the ventilator. The ventilator then measures the
then uses a minimal work calculation31 to set the patient flow and volume demand with each breath
frequency–tidal volume pattern that minimizes the and adds both pressure and flow to provide the
combined resistance and compliance components selected proportion of the breathing work. PAV
of work. The ASV algorithm then attempts to mini- has been compared with power steering on an
mize intrinsic PEEP by measuring the expiratory automobile, an analogy that has much truth. Like
time constants (RCe 5 resistance  compliance) PAV, power steering reduces the work to turn the
and providing an expiratory time of at least 3 RCe. wheels but does not automatically steer the car;
With ASV, clinicians must set the desired minute the driver must control the car’s ultimate direction
ventilation and the proportion of that minute just as the patient ultimately must control the
ventilation that the machine is to supply. Ideal magnitude of the breath and the timing of the
body weight also can be used to calculate the breathing pattern.
desired minute ventilation based on metabolic de- Because PAV requires sensors in the ventilator
mands and predicted dead space. Clinicians also circuitry to measure patient effort, it is susceptible
must set the PEEP and FIO2 in the United States to the same sensor performance and intrinsic
(described later in this article). When spontaneous PEEP issues that affect breath triggering in other
efforts occur with ASV, the algorithm responds assisted modes.24 Also like conventional assisted
with fewer mandatory breaths and adjusts inspira- modes, the clinician must set PEEP and FiO2.
tory pressure according to the minimal work tidal Finally, breath termination (cycling) is much
volume considerations listed previously. ASV has like pressure support and is determined by a
been shown to perform as designed, although in clinician-adjustable percentage of maximal inspi-
healthier lungs, tidal volumes may exceed lung- ratory flow.
protective guidelines.30 Meaningful outcome PAV has been shown in multiple studies to
studies do not exist. perform as designed.35,36 However, whether PAV
improves meaningful clinical outcomes (eg, seda-
Feedback Systems Controlling Positive End-
tion needs, shorter needs for mechanical ventila-
Expiratory Pressure and FiO2
tion) remains to be determined.
On a mechanical ventilator, an FiO2 controller A second novel mode is neurally adjusted venti-
conceptually could be coupled to a feedback latory assistance (NAVA), which utilizes a dia-
controller of PEEP to meet oxygenation and me- phragmatic electromyogram (EMG) signal to
chanical goals (ie, PaO2 or SpO2 targets balanced trigger, govern flow, and cycle ventilatory assis-
against lung compliance or plateau pressure). tance.37 The EMG sensor is an array of electrodes
One system approved outside the United States mounted on an esophageal catheter that is posi-
incorporates the PEEP-FiO2 table used by the Na- tioned in the esophagus at the level of the dia-
tional Institutes of Health (NIH) ARDS Network phragm. Ventilator breath triggering is thus
study.32 With this algorithm, PEEP and FiO2 combi- virtually simultaneous with the onset of phrenic
nations are guided by a PaO2 target range of 55 to nerve excitation of the inspiratory muscles, and
80 mm Hg and a plateau pressure limit of 30 to breath cycling is tightly linked to the cessation of
35 cm H2O. Although this table proved safe and inspiratory muscle contraction. Flow delivery is
effective in ARDS Network trials, whether an auto- driven by the intensity of the EMG signal (electrical
mated system using it will improve outcomes has activity of the diaphragm or EADi), and the clinician
yet to be demonstrated. sets a mL/mV gain factor.

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612 MacIntyre

Like PAV, NAVA depends exclusively on patient 12. MacIntyre NR, Branson RD. Feedback enhance-
effort for timing, intensity, and duration of the ments on conventional ventilator breaths. In:
breath. Thus, like PAV, clinicians must set appro- Tobin MJ, editor. Mechanical ventilation, principles
priate alarms and backup positive pressure venti- and practice. 3rd edition. Philadelphia: McGraw
lation, especially for patients with unreliable Hill; 2011. p. 403–14.
respiratory drives. Also like PAV, clinicians must 13. Lellouche F, Brochard L. Advanced closed loops
set PEEP and FiO2. during mechanical ventilation (PAV, NAVA, ASV,
NAVA has been shown to perform as SmartCare). Best Pract Res Clin Anaesthesiol
designed,13,37–39 and conceptually, NAVA should 2009;23:81–93.
provide excellent patient–ventilator synchrony. 14. Bersten AD, Rutten AJ, Vedig AE, et al. Additional
However, data demonstrating improved outcomes work of breathing imposed by endotracheal tubes,
(eg, duration of mechanical ventilation, sedation breathing circuits, and intensive care ventilators.
needs) are lacking. Another concern with NAVA Crit Care Med 1989;17:671–80.
is the expense associated with the EMG sensor. 15. Bersten AD, Rutten AJ, Vedig AE. Efficacy of pres-
sure support in compensating for apparatus work.
Anaesth Intensive Care 1993;21:67–71.
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