II

PHYSICAL BASIS
OF MECHANICAL
VENTILATION
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CLASSIFICATION OF 2
MECHANICAL VENTILATORS
AND MODES OF VENTILATION
Robert L. Chatburn

CONTROL SYSTEM MODES OF VENTILATION

Models of Patient–Ventilator Interaction Control Variable
Control Variables Breath Sequence
Phase Variables Targeting Schemes
Trigger Variable Mode Classification
Target Variable VENTILATOR ALARM SYSTEMS
Cycle Variable
Baseline Variable THE FUTURE
SUMMARY AND CONCLUSION

A good ventilator classification scheme describes how venti- chapter; these topics have been treated elsewhere.7,8 The
lators work in general terms, but with enough detail so that chapter does, however, explore in detail control schemes
one particular model can be distinguished from others. It and ventilator modes because these directly affect patient
facilitates description by focusing on key attributes in a logi- management.
cal and consistent manner. A clear description allows us to
quickly assess new facts in relation to our previous knowl-
edge. Learning the operation of a new ventilator or describ- CONTROL SYSTEM
ing it to others then becomes much easier. Understanding
how the ventilator operates, we can then anticipate appropri- Models of Patient–Ventilator Interaction
ate ventilator management strategies for particular clinical
situations. The classification system described in this chapter To understand how a machine can be controlled to replace
is based on previously published work.1–7 or supplement the natural function of breathing, we need to
A ventilator is simply a machine, a system of related ele- first understand something about the mechanics of breath-
ments designed to alter, transmit, and direct energy in a pre- ing itself. The study of mechanics deals with forces, displace-
determined manner to perform useful work. We put energy ments, and the rate of change of displacement. In physiology,
into the ventilator in the form of electricity (energy = volts force is measured as pressure (pressure = force/area), dis-
× amps × time) or compressed gas (energy = pressure × placement as volume (volume = area × displacement), and
volume). That energy is transmitted or transformed (by the the relevant rate of change as flow [average flow = Δvolume/
ventilator’s drive mechanism) in a predetermined manner Δtime; instantaneous flow (Vɺ ) = dv /dt , the derivative of vol-
(by the control circuit) to augment or replace the patient’s ume with respect to time]. Specifically, we are interested in
muscles in performing the work of breathing. Thus to the pressure necessary to cause a flow of gas to enter the air-
understand mechanical ventilators in general, we must first way and increase the volume of the lungs.
understand their basic functions: (a) power input, (b) power The study of respiratory mechanics is essentially the
transmission or conversion, (c) control scheme, and (d) out- search for simple but useful models of respiratory system
put. This simple format can be expanded to add as much mechanical behavior. Figure 2-1 illustrates the process by
detail as desired (Table 2-1). which the respiratory system is represented first by a graphi-
A discussion of input power sources and power con- cal model, and then by a mathematical model based on the
version and transmission is beyond the scope of this graphical model. Pressure, volume, and flow are measurable

45
46 Part II Physical Basis of Mechanical Ventilation

Resistive pressure is the product of resistance (R = Δpressure/

TABLE 2-1: OUTLINE OF VENTILATOR
Δflow) and flow. Thus, Eq. (1) can be expanded to yield the
CLASSIFICATION SYSTEM
following equation for inspiration:
I. Input IV. Output ˙
Pvent + Pmus = EV + RV
A. Pneumatic A. Pressure waveforms (2)
B. Electri 1. Rectangular
1. AC 2. Exponential
The combined ventilator and muscle pressure causes volume
2. DC (battery) 3. Sinusoidal and flow to be delivered to the patient. (Of course, muscle
II. Power conversion and 4. Oscillating pressure may subtract rather than add to ventilator pres-
transmission B. Volume waveforms sure in the case of patient–ventilator dyssynchrony, in which
A. External compressor 1. Ascending ramp case both volume and flow delivery are reduced.) Pressure,
B. Internal compressor 2. Sinusoidal volume, and flow are functions of time and are called vari-
C. Output control C. Flow waveforms ables. They are all measured relative to their values at end-
valves 1. Rectangular
III. Control scheme 2. Ascending ramp
expiration. Elastance and resistance are assumed to remain
A. Control circuit 3. Descending ramp constant and are called parameters.
1. Mechanical 4. Sinusoidal For passive expiration, both ventilator and muscle pres-
2. Pneumatic V. Alarms sure are absent, so Eq. (2) becomes
3. Fluidic A. Input power alarms
4. Electric 1. Loss of electric power − RVɺ = EV (3)
5. Electronic 2. Loss of pneumatic power
B. Control variables B. Control circuit alarms The negative sign on the left side of the equation indicates
1. Pressure 1. General systems failure flow in the expiratory direction. This equation also shows
2. Volume 2. Incompatible ventilator that passive expiratory flow is generated by the energy stored
3. Time settings
in the elastic compartment (i.e., lungs and chest wall) during
C. Phase variables 3. Warnings (e.g., inverse
1. Trigger inspiratory-to-expiratory inspiration.
2. Target timing ratio) Equation (2) shows that if the patient’s respiratory mus-
3. Cycle C. Output alarms (high/low cles are not functioning, muscle pressure is zero, and the
4. Baseline conditions) ventilator must generate all the pressure for inspiration.
D. Modes of ventilation 1. Pressure On the other hand, a ventilator is not needed for normal
1. Control variable 2. Volume spontaneous breathing (i.e., vent pressure = 0). Between
2. Breath sequence 3. Flow
3. Targeting 4. Time
those two extremes, an infinite number of combinations of
schemes a. Frequency muscle pressure (i.e., patient effort) and ventilator pressure
b. Inspiratory time are possible under the general heading of “partial ventila-
c. Expiratory time tor support.” The equation of motion also gives the basis for
5. Inspired gas defining an assisted breath as one for which ventilator pres-
a. Temperature sure rises above baseline during inspiration or falls below
b. FIO2
baseline during expiration.

Control Variables
variables in the mathematical model that change with time In the equation of motion, the mathematical form of any of
over the course of one inspiration and expiration. The rela- the three variables (i.e., pressure, volume, or flow as func-
tion among them is described by the equation of motion for tions of time) can be predetermined, making it the inde-
the respiratory system.9 The derivation of this equation stems pendent variable and making the other two the dependent
from a force-balance equation that is an expression of New- variables. We now have a theoretical basis for classifying ven-
ton’s third law of motion (for every action, there is an equal tilators as pressure, volume, or flow controllers. Thus, during
and opposite reaction): pressure-controlled ventilation, pressure is the independent
variable and may take the form of, say, a step function (i.e.,
PTR = PE + PR (1)
a rectangular pressure waveform). The shapes of the vol-
where PTR is the transrespiratory pressure (i.e., pressure ume and flow waveforms for a passive respiratory system
at the airway opening minus pressure at the body surface), (Pmus = 0) then depends on the shape of the pressure wave-
PE is the pressure caused by elastic recoil (elastic load), and form as well as the parameters of resistance and compliance.
PR is the pressure caused by flow resistance (resistive load). On the other hand, during volume-controlled ventilation, we
Transrespiratory pressure can have two components, can specify the shape of the volume waveform making flow-
one generated by the ventilator (P vent) and one generated by dependent and pressure-dependent variables. The same rea-
the respiratory muscles (Pmus). Elastic recoil pressure is the soning applies to a flow controller. Notable exceptions are
product of elastance (E = Δpressure/Δvolume) and volume. interpulmonary percussive ventilation, and high-frequency
 Chapter 2 Classification of Mechanical Ventilators and Modes of Ventilation 47

Flow

Transairway
pressure

Transrespiratory
pressure
Transthoracic
pressure
Volume

FIGURE 2-1 The respiratory system is often modeled as a single flow resistance (representing the endotracheal tube and the airways) connected
to an elastic chamber (representing the lungs and chest wall). Flow through the airways is generated by transairway pressure (pressure at the airway
opening minus pressure in the lungs). Expansion of the elastic chamber is generated by transthoracic pressure (pressure in the lungs minus pressure
on the body surface). Transrespiratory pressure (pressure at the airway opening minus pressure on the body surface) is the sum of these two pressures
and is the total pressure required to generate inspiration. The “airway-pressure” gauge on a positive-pressure ventilator displays transrespiratory
pressure.

oscillatory ventilation, both of which control only the dura- A particular variable is measured and used to start, sustain,
tion of flow pulses; the resulting airway pressure pulses and end each phase. In this context, pressure, volume, flow,
along with actual inspiratory flows and volumes depend on and time are referred to as phase variables.11 Figure 2-2 shows
the instantaneous values of respiratory system impedance. the criteria for determining phase variables.
Because neither pressure, volume, nor flow in the equation
of motion are predetermined, we would classify this type of
device as a “time controller.” Trigger Variable
It follows from the preceding discussion that any conceiv-
able ventilator can control only one variable at a time: pres- All ventilators measure one or more variables associated with
sure, volume, or flow. Because volume and flow are inverse the equation of motion (i.e., pressure, volume, flow, or time).
functions of one another, we can simplify our discussion Inspiration is started when one of these variables reaches a
and consider only pressure and volume as control variables. preset value. Thus, the variable of interest is considered an
I discuss later in “Modes of Ventilation” exactly how ventila- initiating, or trigger, variable. Time is a trigger variable when
tor control systems work. We will see that it is possible for the ventilator starts a breath according to a set frequency
a ventilator to switch quickly from one control variable to independent of the patient’s spontaneous efforts. Pressure is
another, not only from breath to breath, but even during a the trigger variable when the ventilator senses a drop in base-
single inspiration. line pressure caused by the patient’s inspiratory effort and
begins a breath independent of the set frequency. Flow or
volume are the trigger variables when the ventilator senses
Phase Variables the patient’s inspiratory effort in the form of either flow of
volume into the lungs.
Because breathing is a periodic event, the ventilator must Flow triggering reduces the work the patient must per-
be able to control a number of variables during the respira- form to start inspiration.12 This is so because work is pro-
tory cycle (i.e., the time from the beginning of one breath portional to the volume the patient inspires times the
to the beginning of the next). Mushin et al10 proposed that change in baseline pressure necessary to trigger. Pressure
this time span be divided into four phases: the change from triggering requires some pressure change and hence an
expiration to inspiration, inspiration, the change from inspi- irreducible amount of work to trigger. With flow or volume
ration to expiration, and expiration. This convention is triggering, however, baseline pressure need not change, and
useful for examining how a ventilator starts, sustains, and theoretically, the patient need do no work on the ventilator
stops an inspiration and what it does between inspirations. to trigger.
48 Part II Physical Basis of Mechanical Ventilation

Inspiration is Inspiration is Inspiration is Inspiration is

Pressure triggered Volume triggered Flow triggered Time triggered

Yes Yes Yes

Does inspiration Does inspiration Does inspiration Inspiration starts

start because a preset No start because a preset No start because a preset No because a preset time
pressure is detected? volume is detected? flow is detected? interval has elapsed.
Observation and previous knowledge

Inspiration is Inspiration is Inspiration is

Pressure targeted Volume targeted Flow targeted

Yes Yes Yes

Does peak pressure Does peak volume Does peak flow reach No variables are
reach a preset value No reach a preset value No a preset value before No targeted during
before inspiration before inspiration inspiration ends? inspiration.
ends? ends?

Inspiration is Inspiration is Inspiration is Inspiration is

Pressure cycled Volume cycled Flow cycled Time cycled

Yes Yes Yes

Does expiration start Does expiration start Does expiration start Expiration starts
because a preset No because a preset No because a preset No because a preset
pressure is met? volume is met? flow is met? time is met.
FIGURE 2-2 Criteria for determining the phase variables during a ventilator-assisted breath.

The patient effort required to trigger inspiration is Organization’s use of the term limit as applying to alarm situ-
determined by the ventilator’s sensitivity setting. Some ven- ations only.
tilators indicate sensitivity qualitatively (“min” or “max”). Clinicians often confuse target variables with cycle vari-
Alternatively, a ventilator may specify a trigger threshold ables. To cycle means “to end inspiration.” A cycle variable
quantitatively (e.g., 5 cm H2O below baseline). Once the always ends inspiration. A target variable does not terminate
trigger variable signals the start of inspiration, there is inspiration; it only sets an upper bound for pressure, volume,
always a short delay before flow to the patient starts. This or flow (Fig. 2-3).
delay is called the response time and is secondary to the
signal-processing time and the mechanical inertia of the
drive mechanisms. It is important for the ventilator to have Cycle Variable
a short response time to maintain optimal synchrony with
patient inspiratory effort. The inspiratory phase always ends when some variable
reaches a preset value. The variable that is measured and
used to end inspiration is called the cycle variable. The cycle
Target Variable variable can be pressure, volume, flow, or time. Manual
cycling is also available on some ventilators.
Here target means restricting the magnitude of a variable When a ventilator is set to pressure cycle, it delivers flow
during inspiration. A target variable is one that can reach and until a preset pressure is reached, at which time inspiratory
maintain a preset level before inspiration ends (i.e., it does flow stops and expiratory flow begins. The most common
not end inspiration). Pressure, flow, or volume can be tar- application of pressure cycling on mechanical ventilators is
get variables and actually all can be active for a single breath for alarm settings.
(e.g., using the Pmax feature on a Dräger ventilator). Note that When a ventilator is set to volume cycle, it delivers flow
time cannot be a target variable because specifying an inspi- until a preset volume has passed through the control valve.
ratory time would cause inspiration to end, violating the pre- By definition, as soon as the set volume is met, inspiratory
ceding definition. Astute readers may notice that in the past flow stops and expiratory flow begins. If expiration does not
I have used the term limit where here I have used target. This begin immediately after inspiratory flow stops, then an inspi-
was done to be consistent with the International Standards ratory hold has been set, and the ventilator is, by definition,
 Chapter 2 Classification of Mechanical Ventilators and Modes of Ventilation 49

A B C

Ventilator
pressure
Volume
Flow

FIGURE 2-3 This figure illustrates the distinction between the terms target and cycle. A. Inspiration is pressure-targeted and time-cycled. B. Flow is
targeted, but volume is not, and inspiration is volume-cycled. C. Both volume and flow are targeted, and inspiration is time-cycled. (Reproduced, with
permission, from Chatburn.6)

time cycled (see Fig. 2-3). Note that the volume that passes Time cycling means that expiratory flow starts because a
through the ventilator’s output control valve is never exactly preset inspiratory time interval has elapsed.
equal to the volume delivered to the patient because of the
volume compressed in the patient circuit. Some ventilators Baseline Variable
use a sensor at the Y-connector (such as the Dräger Evita
4 with the neonatal circuit) for more accurate tidal volume The baseline variable is the parameter controlled during expi-
measurement. Others measure volume at some point inside ration. Although pressure, volume, or flow could serve as the
the ventilator, and the operator must know whether the ven- baseline variable, pressure control is the most practical and
tilator compensates for compressed gas in its tidal volume is implemented by all modern ventilators. Baseline or expi-
readout. ratory pressure is always measured and set relative to atmo-
When a ventilator is set to flow cycle, it delivers flow spheric pressure. Thus, when we want baseline pressure to
until a preset level is met. Flow then stops, and expiration equal atmospheric pressure, we set it to zero. When we want
begins. The most frequent application of flow cycling is in baseline pressure to exceed atmospheric pressure, we set a
the pressure-support mode. In this mode, the control vari- positive value, called positive end-expiratory pressure (PEEP).
able is pressure, and the ventilator provides the flow neces-
sary to meet the inspiratory pressure target. In doing so, flow
starts out at a relatively high value and decays exponentially MODES OF VENTILATION
(assuming that the patient’s respiratory muscles are inactive
after triggering). Once flow has decreased to a relatively low The general goals of mechanical ventilation are to pro-
value (such as 25% of peak flow, typically preset by the man- mote safety, comfort, and liberation (Table 2-2).1 Specific
ufacturer), inspiration is cycled off. Manufacturers often set objectives under these goals include ensuring adequate gas
the cycle threshold slightly above zero flow to prevent inspi- exchange, avoiding ventilator induced lung injury, optimiz-
ratory times from getting so long that patient synchrony is ing patient-ventilator synchrony, and minimizing the dura-
degraded. On some ventilators, the flow-cycle threshold may tion of ventilation. The preset pattern of patient-ventilator
be adjusted by the operator to improve patient synchrony. interaction designed to achieve these objectives is referred to
Increasing the flow-cycle threshold decreases inspiratory as a mode of ventilation. Specifically, a mode can be classified
time and vice versa. according to the outline in Table 2-3.2
50 Part II Physical Basis of Mechanical Ventilation

TABLE 2-2: GOALS AND OBJECTIVES OF TABLE 2-3: OUTLINE OF MODE

MECHANICAL VENTILATION CLASSIFICATION SYSTEM
1. Promote safety 1. Primary control variable
a. Optimize ventilation–perfusion of the lung a. Pressure
i. Maximize alveolar ventilation b. Volume
ii. Minimize shunt 2. Breath sequence
b. Optimize pressure–volume curve a. Continuous mandatory ventilation (CMV)
i. Minimize tidal volume b. Intermittent mandatory ventilation (IMV)
ii. Maximize compliance c. Continuous spontaneous ventilation (CSV)
2. Promote comfort 3. Primary targeting scheme
a. Optimize patient–ventilator synchrony a. Set-point
i. Maximize trigger–cycle synchrony b. Dual
ii. Minimize auto-PEEP c. Servo
iii. Maximize flow synchrony d. Adaptive
iv. Coordinate mandatory and spontaneous breaths e. Optimal
b. Optimize work demand versus work delivered f. Intelligent
i. Minimize inappropriate shifting of work from
ventilator to patient 4. Secondary targeting scheme
a. Set-point
3. Promote liberation b. Servo
a. Optimize the weaning experience c. Adaptive
i. Minimize adverse events d. Optimal
ii. Minimize duration of ventilation e. Intelligent
Reproduced with permission from Chatburn RL, Mireles-Cabodevila E. Closed
loop control of mechanical ventilation. Respir Care. 2011;56(1):85–98.

flow changes caused by hiccups or cardiogenic oscillations.

Control Variable It allows, however, the superimposition of, for example, a
spontaneous breath on a mandatory breath or vice versa. The
I have already mentioned that pressure, volume, or flow can flows are paired by size, not necessarily by timing. In air-
be controlled during inspiration. When discussing modes way pressure-release ventilation, for example, there is a large
I will refer to inspiration as being pressure-controlled or inspiration (transition from low pressure to high pressure)
volume-controlled. Ignoring flow control is justified because possibly followed by a few small inspirations and expira-
when the ventilator controls volume directly (i.e., using a tions, followed finally by a large expiration (transition from
volume-feedback signal), flow is controlled indirectly, and high pressure to low pressure). These comprise several small
vice versa (i.e., mathematically, volume is the integral of flow, spontaneous breaths superimposed on one large manda-
and flow is the derivative of volume). tory breath. During high-frequency oscillatory ventilation,
There are clinical advantages and disadvantages to vol- in contrast, small mandatory breaths are superimposed on
ume and pressure control. To keep within the scope of this larger spontaneous breaths.
chapter, we can just say that volume control results in a more A spontaneous breath, in the context of mechanical ven-
stable minute ventilation (and hence more stable blood gases) tilation, is a breath for which the patient determines both
than pressure control if lung mechanics are unstable. On the the timing and the size. The start and end of inspiration may
other hand, pressure control allows better synchronization be determined by the patient, independent of any machine
with the patient because inspiratory flow is not constrained settings for inspiratory time and expiratory time. That is,
to a preset value. Although the ventilator must control only the patient both triggers and cycles the breath. On some
one variable at a time during inspiration, it is possible to ventilators, the patient may make short, small spontaneous
begin a breath-in pressure control and (if certain criteria are efforts during a longer, larger mandatory breath, as in the
met) switch to volume control or vice versa (referred to as case of airway pressure-release ventilation. It is important to
dual targeting, described in “Targeting Schemes” below). make a distinction between spontaneous breaths and assisted
breaths. An assisted breath is one for which the ventilator
does some work for the patient, as indicated by an increase
Breath Sequence in airway pressure (i.e., Pvent) above baseline during inspira-
tion or below baseline during expiration. For example, in the
The breath sequence is the pattern of mandatory or sponta- pressure-support mode, each breath is assisted because airway
neous breaths that the mode delivers. A breath is a positive pressures rise to the pressure-support setting above PEEP (i.e.,
airway flow (inspiration) relative to baseline, and it is paired Pvent > 0). Each breath is also spontaneous because the patient
(by size) with a negative airway flow (expiration), both asso- both triggers and cycles the breath. The patient may cycle the
ciated with ventilation of the lungs. This definition excludes breath in the pressure-support mode by actively exhaling, but
 Chapter 2 Classification of Mechanical Ventilators and Modes of Ventilation 51

even if the patient is passive at end-inspiration, the patient’s controlled mandatory breaths on infant ventilators. The
resistance and compliance determine the cycle point and thus key distinction between CMV and IMV is that with CMV,
the size of the breath for a given pressure-support setting. In the ventilator attempts to deliver a mandatory breath every
contrast, for a patient on continuous positive airway pressure, time the patient makes an inspiratory effort (unless a man-
each breath is spontaneous but unassisted. Breaths are spon- datory breath is already in progress). This means that
taneous because the patient determines the timing and size of during CMV, if the operator decreases the ventilator rate,
the breaths without any interference by the ventilator. Breaths the level of ventilator support is unaffected as long as the
during continuous positive airway pressure are not assisted patient continues making inspiratory efforts. With IMV,
because airway pressure is controlled by the ventilator to be the rate setting directly affects the number of mandatory
as constant as possible (i.e., Pvent = 0). Understanding the dif- breaths and hence the level of ventilator support. Thus,
ference between assisted and unassisted spontaneous breaths CMV is normally viewed as a method of “full ventilator
is very important clinically. When making measurements of support,” whereas IMV is usually viewed as a method of
tidal volume and respiratory rate for calculation of the rapid- partial ventilator support. Of course, actual “full ventila-
shallow breathing index, for example, the breaths must be tory support” can only be achieved if the patient is making
spontaneous and unassisted. If they are assisted (e.g., with no inspiratory efforts, for example, is paralyzed, but the
pressure support), an error of 25% to 50% may be introduced. term is often used loosely to mean supplying as much sup-
A mandatory breath is any breath that does not meet the port as possible for a given patient condition.
criteria of a spontaneous breath, meaning that the patient
Given the two ways to control inspiration (i.e., pressure
has lost control over the timing and/or size. Thus, a manda-
and volume) and the three breath sequences (i.e., CMV, IMV,
tory breath is one for which the start or end of inspiration
or CSV), there are five possible breathing patterns; volume
(or both) is determined by the ventilator, independent of the
control (VC)-CMV, VC-IMV, pressure control (PC)-CMV,
patient; that is, the machine triggers and/or cycles the breath.
PC-IMV, PC-CSV (see Table 2-2). VC-CSV is not possible
It is possible to superimpose a short mandatory breath on
because volume control implies that inspiration ends after a
top of a longer spontaneous breath, as in the case of high-
preset tidal volume is delivered, hence violating the patient
frequency oscillatory ventilation.
cycling criterion of a spontaneous breath.
Having defined spontaneous and mandatory breaths, there
are three possible breath sequences, designated as follows:
• Continuous spontaneous ventilation (CSV). All breaths are Targeting Schemes
spontaneous.
• Intermittent mandatory ventilation (IMV). Spontane- Targeting schemes are feedback control systems used by
ous breaths are permitted between mandatory breaths. mechanical ventilators to deliver specific ventilatory pat-
When the mandatory breath is triggered by the patient, terns.1 The targeting scheme is a key component of a mode
it is commonly referred to as synchronized IMV. Because classification system. Before we can describe specific target-
the trigger variable can be specified in the description of ing schemes used by ventilators, we must first appreciate the
phase variables, I will use IMV instead of synchronized basic concepts of engineering control theory.
IMV to designate general breath sequences. The term closed-loop control refers to the use of a feed-
• Continuous mandatory ventilation (CMV). Spontaneous back signal to adjust the output of a system. Ventilators use
breaths are not permitted between mandatory breaths, as closed-loop control to maintain consistent pressure and flow
the intent is to provide a mandatory breath for every patient waveforms in the face of changing patient/system condi-
inspiratory effort. CMV originally meant that every breath tions. This is accomplished by using the output as a feedback
was mandatory. The development of the “active exhalation signal that is compared to the operator-set input. The differ-
valve,” however, made it possible for the patient to breathe ence between the two is used to drive the system toward the
spontaneously during a mandatory pressure-controlled desired output. For example, pressure-control modes use
breath on some ventilators. In fact, it was always possible airway pressure as the feedback signal to control gas flow
for the patient to breathe spontaneously during pressure- from the ventilator. Figure 2-4 is a schematic of a general

Disturbances

Error Controller Effector Manipulated Controlled

Input Plant
+ signal (Software) (Hardware) variable variable
– (Output)

Feedback signal
FIGURE 2-4 Generalized control circuit (see text for explanation). The “plant” in a control circuit for mechanical ventilation is the patient.
(Reproduced with permission from Chatburn RL. Mireles-Cabodevila E, Closed loop control of mechanical ventilation. Respir Care. 2011;56(1):
85–98.)
52 Part II Physical Basis of Mechanical Ventilation

control system. The input is a reference value (e.g., operator (relationship between the input and the output of the con-
preset inspiratory pressure) that is compared to the actual troller) as a targeting scheme. The history of these schemes
output value (e.g., instantaneous value of airway pressure). clearly shows an evolutionary trend toward increasing lev-
The difference between those two values is the error signal. els of automation. In fact, we can identify three groups of
The error signal is passed to the controller (e.g., the software targeting schemes based on increasing levels of autonomy:
control algorithm). The controller converts the error signal manual, servo, and automatic. Manual targeting schemes
into a signal that can drive the effector (e.g., the hardware) require the operator to adjust all the target values. Servo
to cause a change in the manipulated variable (e.g., inspira- targeting schemes are unique in that there are no static
tory flow). The relationship between the input and the out- target values; rather, the operator sets the parameters of a
put of the controller is called the transfer function in control mathematical model that drives the ventilator’s output to
theory. Engineers need to understand the transfer function follow a dynamic signal (like power steering on an auto-
in terms of complex mathematical equations. Clinicians, mobile). Automatic targeting schemes enable the ventila-
however, need only understand the general operation of tor to set some or all of the ventilatory targets, using either
the function in terms of how the mode affects the patient’s mathematical models of physiologic processes or artificial-
ventilatory pattern, and we will use that frame of reference intelligence algorithms.
in defining targeting schemes. The “plant” in Figure 2-4 The basic concept of closed-loop control has evolved into
refers to the process under control. In our case, the plant is at least six different ventilator targeting schemes (set-point,
the patient and the delivery circuit connecting the patient dual, servo, adaptive, optimal, and intelligent). These tar-
to the ventilator. The plant is the source of the “noise” that geting schemes are the foundation that makes possible sev-
causes problems with patient–ventilator synchrony. At one eral dozen apparently different modes of ventilation. Once
extreme, a paralyzed patient and an intact delivery circuit we understand how these control types work, many of the
pose little challenge for a modern ventilator to deliver a apparent differences are seen to be similarities. We then
predetermined ventilatory pattern, and thus synchrony is avoid a lot of the confusion surrounding ventilator market-
not an issue. At the opposite extreme is a patient with an ing hype and begin to appreciate the true clinical capabilities
intense, erratic respiratory drive and a delivery circuit with of different ventilators.
leaks (e.g., around an uncuffed endotracheal tube) making
patient–ventilator synchrony virtually impossible. The chal- SET-POINT
lenge for both clinicians and engineers is to develop tech-
nology and procedures for dealing with this wide range of In set-point targeting, the operator sets specific target values
circumstances. and the ventilator attempts to deliver them (Fig. 2-5). The
The plant alters the manipulated variable to generate the simplest examples for volume-control modes are tidal vol-
feedback signal of interest as the control (output) variable. ume and inspiratory flow. For pressure-control modes, the
Continuing with the example above, the manipulated vari- operator may set inspiratory pressure and inspiratory time
able is flow, but the feedback control variable is pressure (i.e., or cycle threshold.
ventilator flow times plant impedance equals airway pres-
sure), as in pressure-control modes. DUAL
Closed-loop control can also refer to the use of feedback
As it relates to mechanical ventilation, volume control means
signals to control the overall pattern of ventilation, beyond
that inspired volume, as a function of time, is predetermined
a single breath, such as the use of end-tidal carbon dioxide
by the operator before the breath begins. In contrast, pres-
tension as a feedback signal to control minute ventilation. sure control means that inspiratory pressure as a function of
The process of “setting” or adjusting a ventilation mode
time is predetermined. “Predetermined” in this sense means
can be thought of as presetting various target values, such as
that either pressure or volume is constrained to a specific
tidal volume, inspiratory flow, inspiratory pressure, inspira-
mathematical form. In the simple case where either pressure
tory time, frequency, PEEP, oxygen concentration, and end-
or flow are preset constant values (e.g., set-point targeting, as
tidal carbon dioxide concentration. The term target is used explained above), we can say that they are the independent
for two reasons. First, just like in archery, a target is aimed
at but not necessarily hit, depending on the precision of the
control system. An example is setting a target value for tidal
Disturbances
volume and allowing the ventilator to adjust the inspiratory
pressure over several breaths to finally deliver the desired Set-point
Operator
value. In this case, we could more accurately talk about deliv- Pressure Ventilator Patient
Volume
ering an average target tidal volume over time. Flow
The second reason for using target is because the term Flow or volume
control is overused and we need it to preserve some funda- Pressure
mental conventions regarding modes such as volume control FIGURE 2-5 Set-point targeting. (Reproduced, with permission, from
versus pressure control. From this use of the term target, we Chatburn RL. Computer control of mechanical ventilation. Respir Care.
can logically refer to the control system transfer function 2004;49:507–515.)
 Chapter 2 Classification of Mechanical Ventilators and Modes of Ventilation 53

variables in the equation of motion. The equation of motion provides the safety of a guaranteed minimum tidal volume
for the respiratory system is a general mathematical model of with the patient comfort of flow synchrony provided by pres-
patient–ventilator interaction: sure control.
P(t ) = EV (t ) + RVɺ (t ) (4)
SERVO
where P(t) is inspiratory pressure as a function of time (t), E The term servo was coined by Joseph Farcot in 1873 to
is respiratory-system elastance, V(t) is volume as a function describe steam-powered steering systems. Later, hydraulic
of time, R is respiratory-system resistance, and Vɺ is flow as a “servos” were used to position antiaircraft guns on warships.
function of time. Thus, for example, if pressure is the inde- Servo control specifically refers to a control system that con-
pendent variable, then both volume and flow are dependent verts a small mechanical motion into one requiring much
variables, indicating pressure control. If volume is the inde- greater power, using a feedback mechanism. As such, it
pendent variable, then pressure is the dependent variable, offers a substantial advantage in terms of creating ventilation
indicating volume control. Because volume is the integral of modes capable of a high degree of synchrony with patient
flow, if Vɺ is predetermined, then so is V(t). Therefore, for breathing efforts. That is, ventilator work output can be
simplicity, we include the case of flow being the independent made to match patient work demand with a high degree of
variable as a form of volume control. fidelity. We apply the name servo control to targeting schemes
Only one variable (i.e., pressure or volume) can be inde- in which the ventilator’s output automatically follows a vary-
pendent at any moment, but a ventilator controller can ing input. This includes proportional-assist ventilation (PAV;
switch between the two during a single inspiration. When Fig. 2-6),14 automatic tube compensation (ATC),15 and neu-
this happens, the targeting scheme is called dual set-point rally adjusted ventilatory assist (NAVA),16 in which the air-
control or dual targeting. There are two basic ways that way pressure signal not only follows but amplifies signals
ventilators have implemented dual targeting. One way is to that are surrogates for patient effort (i.e., volume, flow, and
start inspiration in volume control and then switch to pres- diaphragmatic electrical signals). Note that the term servo
sure control if one or more preset thresholds are met (e.g., a control has been loosely used since it was coined to refer to
desired peak airway pressure target). An example of such a any type of general feedback control mechanism, but I am
threshold is the operator-set Pmax in volume control on the using it in a very specific manner, as it applies to ventilator
Dräger Evita XL ventilator. The other form of dual targeting targeting schemes.
is to start inspiration in pressure control and then switch to
volume control (e.g., if a preset tidal volume has not been
met when flow decays to a preset value). This was originally
described as “volume-assured pressure-support ventila- Disturbances
tion,”13 but is currently only available as a mode called “Vol- Set-point
Operator
ume Control Assist Control with Machine Volume” in the Elastic load Ventilator Patient
CareFusion Avea ventilator.
Resistive load
Dual targeting is an attempt to improve the synchrony Pressure, volume, and flow
between patient and ventilator. This can be seen in the equa-
tion of motion if a term representing the patient inspiratory
force (muscle pressure or Pmus) is added: Pmus = Loadnormal + Loaddisease

P(t) = EV(t) + RV(t) − Pmus(t) (5)

.
With set-point targeting in volume control modes, vol- Pvent = K1 × V + K2 × V
ume and flow are preset. Therefore, if the patient makes an
inspiratory effort (i.e., Pmus(t) > 0), then the equation dic-
tates that transrespiratory-system pressure, P(t), must fall. Pmus + Pvent = Loadnormal + Loaddisease
Because work is the result of both pressure and volume deliv-
FIGURE 2-6 Servo targeting is the basis for the proportional-assist
ery (i.e., work = ∫Pdv), if pressure decreases, the work the
mode. In this mode, the operator sets targets for elastic and resis-
ventilator does on the patient decreases and hence we have tive unloading. The ventilator then delivers airway pressure in pro-
asynchrony of work demand on the part of the patient versus portion to the patient’s own inspiratory volume and flow. When the
work output on the part of the ventilator. patient’s muscles have to contend with an abnormal load secondary
With set-point pressure control, transrespiratory pressure to disease, proportional assist allows the operator to set amplifica-
is preset. Consequently, if the patient makes an inspiratory tion factors (K1 and K2) on the feedback volume and flow signals. By
effort, both volume and flow increase. With constant pres- amplifying volume and flow, the ventilator generates a pressure that
supports the abnormal load, freeing the respiratory muscles to sup-
sure and increased volume, work per liter for the breath stays port only the normal load caused by the natural elastance and resis-
constant. Although this gives better work synchrony than tance of the respiratory system. (Reproduced, with permission, from
does volume control, it is not ideal. Nevertheless, merging of Chatburn RL. Computer control of mechanical ventilation. Respir
volume and pressure control using a dual targeting scheme Care. 2004;49:507–515.)
54 Part II Physical Basis of Mechanical Ventilation

Set-point Set-point Model

Operator Minimize
Volume Adjustment
work
Exhaled volume
Pressure
Disturbances Set-point Set-point
Operator
Patient Adjustment

Exhaled volume
weight
Ventilator Patient

Frequency
Pressure

Volume
Flow Disturbances

Pressure
FIGURE 2-7 Adaptive targeting. Notice that the operator has stepped Ventilator Patient
back from direct control of the within-breath parameters of pressure
and flow. Examples of adaptive targeting are pressure-regulated volume Flow
control (PRVC) on the Siemens ventilator and autoflow on the Dräger
Evita 4 ventilator. (Reproduced, with permission, from Chatburn RL. Pressure
Computer control of mechanical ventilation. Respir Care. 2004;49: FIGURE 2-8 Optimal targeting. A static mathematical model is used
507–515.) to optimize some performance parameter, such as work of breath-
ing. The only commercially available form of optimal targeting is the
adaptive-support ventilation (ASV) mode on the Hamilton Galileo ven-
tilator. (Reproduced, with permission, from Chatburn RL. Computer
ADAPTIVE control of mechanical ventilation. Respir Care. 2004;49:507–515.)
An adaptive targeting scheme involves modifying the func-
tion of the controller to cope with the fact that the system
parameters being controlled are time varying. As it applies breathing, mimic natural breathing, stimulate spontaneous
to mechanical ventilation, adaptive targeting schemes allow breathing, and reduce weaning time.20 The operator inputs
the ventilator to set some (or conceivably all) of the targets the patient’s weight. From that, the ventilator estimates the
in response to varying patient conditions. Modern inten- required minute alveolar ventilation, assuming a normal
sive care unit ventilators may use adaptive flow targeting as dead space fraction. Next, an optimum frequency is calcu-
a more accurate way to deliver volume control modes than lated based on work by Otis et al21 that predicts a frequency
set-point targeting. For example, the Covidien PB 840 venti- resulting in the least mechanical work rate:20
lator automatically adjusts inspiratory flow between breaths
MV − fVD 
to compensate for volume compression in the patient circuit −1 + 1 + 4π 2 RC E 
and thus achieving an average target tidal volume equal to  VD 
the operator-set value.17 Aside from this application of adap- f = (6)
2π 2 RC E
tive targeting, there are four distinct approaches to basic
adaptive targeting, which are represented by the mode names where MV is predicted minute ventilation (L/min) based on
pressure-regulated volume control (inspiratory pressure auto- patient weight and the setting for percent of predicted MV
matically adjusted to achieve an average tidal volume target, to support, VD is predicted dead space (L) based on patient
Fig. 2-7), mandatory rate ventilation (inspiratory pressure weight, RCE is the expiratory time constant calculated as the
automatically adjusted to maintain a target spontaneous slope of the expiratory flow volume curve and f is the com-
breath frequency), adaptive flow/adaptive I-time (inspiratory puted optimal frequency (breaths/min). The target tidal vol-
time and flow automatically adjusted to maintain a constant ume is calculated as MV/f. The ASV controller uses the Otis
inspiratory time-to-expiratory time ratio of 1:2), and manda- equation to set the tidal volume (Fig. 2-8). As with simple
tory minute ventilation (automatic adjustment of mandatory adaptive pressure targeting, the inspiratory pressure within a
breath frequency to maintain a target minute ventilation). breath is controlled to achieve a constant value and between
breaths the inspiratory pressure is adjusted to achieve a tar-
get tidal volume. Unlike simple adaptive pressure targeting,
OPTIMAL
however, the target is not set by the operator; instead, it is
Optimal targeting is an advanced form of adaptive target- estimated by the ventilator in response to changes in respi-
ing.18 Optimal targeting in this context means that the ven- ratory-system mechanics and patient effort. Individual pres-
tilator controller automatically adjusts the targets of the sure-targeted breaths may be mandatory (time triggered and
ventilatory pattern to either minimize or maximize some time cycled) or spontaneous (flow triggered and flow cycle).
overall performance characteristic (Fig. 2-8). Adaptive- ASV adds some expert rules that put safety limits on fre-
support ventilation (ASV) on the Hamilton ventilators is the quency and tidal volume delivery and reduce the risk of auto-
only commercially available mode to date that uses optimal PEEP. In that sense, this mode may be considered an intelligent
targeting. This targeting scheme was first described by Teh- targeting scheme, or more appropriately, a hybrid system (i.e.,
rani in 199120 and was designed to minimize the work rate of using a mathematical model and artificial intelligence).
 Chapter 2 Classification of Mechanical Ventilators and Modes of Ventilation 55

INTELLIGENT tube vs. tracheostomy tube), the type of humidifier (heat

and moisture exchanger vs. a heated humidifier), and the
Intelligent targeting systems are another form of adaptive tar-
use of automatic tube compensation. Once the lowest level
geting schemes that use artificial-intelligence techniques.22
of inspiratory pressure is reached, a 1-hour observation
The most convincing proof of the concept was presented by
period is started (i.e., a spontaneous breathing trial) during
East et al,23 who used a rule-based expert system for venti-
which the patient’s breathing frequency, tidal volume, and
lator management in a large, multicenter, prospective, ran-
end-tidal CO2 are monitored. Upon successful completion
domized trial. Although survival and length of stay were not
of this step, a message on the screen suggests that the clini-
different between human and computer management, com-
cian “consider separation” of the patient from the ventilator.
puter control resulted in a significant reduction in multior-
This method for automatic weaning reduces the duration of
gan dysfunction and a lower incidence and severity of lung
mechanical ventilation and intensive care unit length of stay
overdistension injury. The most important finding, however,
in a multicenter randomized controlled trial.24,25 The advan-
was that expert knowledge can be encoded and shared success-
tage of artificial intelligence, however, may be less notice-
fully with institutions that had no input into the model. Note
able in environments where natural intelligence is plentiful.
that the expert system did not control the ventilator directly,
Rose et al recently concluded that “Substantial reductions
but rather made suggestions for the human operator. In the-
in weaning duration previously demonstrated were not
ory, of course, the operator could be eliminated.
confirmed when the SmartCare/PS system was compared
There is only one ventilator mode commercially avail-
to weaning managed by experienced critical care specialty
able to date in the United States with a targeting scheme
nurses, using a 1:1 nurse-to-patient ratio. The effect of
that relies entirely on a rule-based expert system (Fig. 2-9).
SmartCare/PS may be influenced by the local clinical orga-
That mode is SmartCare/PS on the Dräger Evita XL venti-
nizational context.”26
lator. This mode is a specialized form of pressure support
The ultimate in ventilator targeting system to date is the
that is designed for true (ventilator led) automatic weaning
artificial neural network (Fig. 2-10).27 Again, this experimen-
of patients. The SmartCare/PS controller uses predefined
tal system does not control the ventilator directly but acts as
acceptable ranges for spontaneous breathing frequency, tidal
a decision-support system. What is most interesting is that
volume, and end-tidal carbon dioxide tension to automati-
the neural network is capable of learning, which offers signifi-
cally adjust the inspiratory pressure to maintain the patient
cant advantages over static mathematical models and even
in a “respiratory zone of comfort.”23
expert rule-based systems.
The SmartCare/PS system divides the control process
Neural nets are essentially data-modeling tools used to
into three steps. The first step is to stabilize the patient
capture and represent complex input–output relationships.
within the “zone of respiratory comfort” defined as com-
A neural net learns by experience the same way a human
binations of tidal volume, respiratory frequency, and end
brain does, by storing knowledge in the strengths of inter-
tidal CO2 values defined as acceptable by the artificial-
node connections. As data-modeling tools, they have been
intelligence program. There are different combinations
used in many business and medical applications for both
depending on whether the patient has chronic obstructive
diagnosis and forecasting.28 A neural network, like an ani-
pulmonary disease or a neuromuscular disorder. The sec-
mal brain, is made up of individual neurons. Signals (action
ond step is to progressively decrease the inspiratory pressure
potentials) appear at the unit’s inputs (synapses). The effect
while making sure the patient remains in the “zone.” The
of each signal may be approximated by multiplying the sig-
third step tests readiness for extubation by maintaining the
nal by some number or weight to indicate the strength of the
patient at the lowest level of inspiratory pressure. The lowest
signal. The weighted signals then are summed to produce
level depends on the type of artificial airway (endotracheal

Ventilator Disturbances
Patient
Weight Controller Effector
Flow Patient
Diagnosis Expert Rules IP (Hardware)

Inspired flow
Pressure

Volume Integrator Expired flow

Frequency

End tidal CO2

FIGURE 2-9 An intelligent targeting system for automatically adjusting pressure support levels (e.g., SmartCare/PS). IP, inspiratory pressure.
(Reproduced, with permission, from Chatburn RL, Mireles-Cabodevila E. Closed loop control of mechanical ventilation. Respir Care. 2011;56(1):85–98.
56 Part II Physical Basis of Mechanical Ventilation

Single neuron

Threshold
Inputs Weights Summation function Output

1
X Σ
0

Neural network

Input First Second Output

layer hidden hidden layer
layer layer
FIGURE 2-10 Neural network structure. A single neuron accepts inputs of any value and weights them to indicate the strength of the synapse. The
weighted signals are summed to produce an overall unit activation. If this activation exceeds a certain threshold, the unit produces an output response.
A network is made up of layers of individual neurons. (Reproduced, with permission, from Chatburn RL. Computer control of mechanical ventilation.
Respir Care. 2004;49:507–515.)

an overall unit activation. If this activation exceeds a cer- system learning from experience so that the control actually
tain threshold, the unit produces an output response. Large spans between patients instead of just between breaths.
numbers of neurons can be linked together in layers (see
Fig. 2-10). The nodes in the diagram represent the summa-
tion and transfer processes. Note that each node contains Mode Classification
information from all neurons. As the network learns, the
weights change, and thus the values at the nodes change, When Mushin et al wrote the classic book on automatic
affecting the final output. ventilation of the lungs,10 the emphasis was on classifying
In summary, ventilator control schemes display a definite ventilators and there were very few modes on each device.
hierarchy of evolutionary complexity. At the most basic level, These devices have undergone a tremendous technological
control is focused on what happens within a breath. We can evolution during the intervening years. As a result, there are
call this manual control, and there is a very direct need for now more than 170 names of modes on ventilators in the
operator input of static set-points. The next level up is what United States alone, with as many as two dozen available
we can call automatic control. Here, set-points are dynamic on a single device. The proliferation of names makes edu-
in that they may be adjusted automatically over time by the cation of end users very difficult, potentially compromis-
ventilator according to some model of desired performance. ing the quality of patient care. In addition, although there
The operator is somewhat removed in that inputs are entered may be more than 170 mode names, these are not uniquely
at the level of the model and take effect over several breaths different modes. Consequently, the emphasis today in
instead of at the level of individual breath control. Finally, describing ventilators must be on classifying modes, shift-
the highest level so far is what might be considered intelligent ing awareness from names to tags. Much has been written
control. Here, the operator can be eliminated altogether. Not on the subject,2,5, 29–31 and this section gives a brief overview
only dynamic set-points but also dynamic models of desired of the development and application of a ventilator mode
performance are permitted. There is the possibility of the taxonomy.
 Chapter 2 Classification of Mechanical Ventilators and Modes of Ventilation 57

You can easily appreciate the motivation for classifying mode can deliver. CSV implies all spontaneous breaths;
modes, just as we do animals or plants (or cars or drugs) IMV allows spontaneous breaths to occur between
because of their large number and variety. The logical basis mandatory breaths and CMV does not.
for a mode taxonomy, however, is not apparent without some 8. There are only five basic ventilatory patterns: VC-CMV,
consideration. This basis has become a teaching system VC-IMV, PC-CMV, PC-IMV, and PC-CSV. All modes
I have developed and tested and is founded on ten simple can be categorizes by these five patterns. This provides
constructs (or aphorisms), each building on the previous one enough practical detail about a mode for most clinical
to yield a practical taxonomy. These aphorisms summarize purposes.
many of the ideas discussed previously in this chapter, and 9. Within each ventilatory pattern there are several variations
there is even some evidence that they are recognized inter- that can be distinguished by their targeting scheme(s).
nationally by clinicians.32 In simplified form, the aphorisms When comparing modes or evaluating the capability of
are as follows: a ventilator, more detail is required than just the ventila-
tory pattern. Modes with the same pattern can be dis-
1. A breath is one cycle of positive flow (inspiration) and neg-
tinguished by describing the targeting schemes they use.
ative flow (expiration). The purpose of a ventilator is to
There are at present only six basic targeting schemes: set-
assist breathing. Therefore, the logical start of a taxonomy
point, dual, servo, adaptive, optimal, and intelligent.
is to define a breath. Breaths are defined such that dur-
10. A mode of ventilation is classified according to its con-
ing mechanical ventilation, small artificial breaths may be
trol variable, breath sequence, and targeting scheme(s).
superimposed on large natural breaths or vice versa.
A practical taxonomy of ventilatory modes is based on
2. A breath is assisted if pressure rises above baseline during
just four levels of detail: the control variable (pressure or
inspiration or falls during expiration. A ventilator assists
volume), the breath sequence (CMV, IMV, or CSV), the
breathing by doing some portion of the work of breath-
targeting scheme used for primary breaths (CMV and
ing. This occurs by delivering volume under pressure.
CSV), and, if applicable, secondary breaths (IMV).
3. A ventilator assists breathing using either pressure con-
trol (PC) or volume control (VC). The equation of In teaching these constructs to respiratory therapists and
motion is the fundamental model for understanding physicians, most educators would agree that knowing a con-
patient–ventilator interaction and hence modes of ven- cept and applying it are two different skills. As with any tax-
tilation. The equation is an expression of the idea that onomy, learning the definitions and mastering the heuristic
only one variable can be predetermined at a time; pres- thinking required to actually categorize specific cases requires
sure or volume (flow control is ignored for simplicity further guidance and some practice. Say, for example, your
and for historical reasons, and because controlling flow task is to compare the capabilities of two major intensive care
directly will indirectly control volume and vice versa). unit ventilator models for a large capital purchase. Memoriz-
4. Breaths are classified according to the criteria that trig- ing the ten aphorisms may not translate into the ability to
ger (start) and cycle (stop) inspiration. A ventilator must classify the modes offered on these two ventilators as a basis
know when to start and stop flow delivery for a given for comparison. To facilitate that skill, I created the three tools
breath. Because starting and stopping inspiratory flow shown in Figures 2-11 and 2-12 and in Table 2-4. Using these
are critical events in synchronizing patient–ventilator tools you can create a simple spreadsheet that defines and
interaction, and because they involve uniquely different compares the modes on any number of ventilators. Table 2-5
operator-influenced factors, they are distinguished by is an example of such a table for the Covidien PB 840 ventila-
giving them different names. tor and the Dräger Evita XL ventilator. When implemented as
5. Trigger and cycle criteria can be either patient or machine a spreadsheet with built-in data-sorting functions, the table
initiated. A major design consideration in creating modes becomes a database with several major uses:
is the ability to synchronize breath delivery with patient
1. A “Rosetta Stone” that can be used to translate from mode
demand and at the same time to guarantee breath delivery
name to mode classification and vice versa. In this way
if the patient is apneic. Therefore, understanding patient–
modes can be identified that are functionally identical but
ventilator interaction means understanding the difference
have different proprietary names.
between machine and patient trigger and cycle events.
2. A tool for engineers to describe performance character-
6. Breaths are classified as spontaneous or mandatory based
istics of individual named modes. Information like this
on both the trigger and cycle criteria. A spontaneous breath
should be available to users in the ventilator’s manual.
arises without apparent external cause. Thus, it is patient
3. A system for clinicians to compare and contrast the capa-
triggered and patient cycled. Any machine involvement
bilities of various modes and ventilators.
in triggering or cycling leads to a mandatory breath. Note
4. A paradigm for educators to use in teaching the basic
that the definition of a spontaneous breath is independent
principles of mechanical ventilation.
of the definition of an assisted or unassisted breath.
7. Ventilators deliver only three basic breath sequences: One can imagine the utility of an expanded database con-
CMV, IMV, and CSV. The two breath classifications taining the classification of all modes on all commercially
logically lead to three possible breath sequences that a available ventilators.
58 Part II Physical Basis of Mechanical Ventilation

Review list of
operator-initiated
Evaluate ventilator
settings and
specifications
ventilator-initiated
settings

Identify what
happens
during a single
breath

VT = Tidal volume
TI = Inspiratory time
Intrabreath
VT is preset Control variable
*Examples:
directly or by flow Yes is
Volume-assist control
and TI* volume
Volume SIMV

Record control
No
variable

Paw = Airway pressure

*Examples: Control variable

CPAP Paw is preset* Yes is
Pressure support pressure
Volume assured pressure support

No

Paw is
proportional to
*Examples: Yes
inspiratory
Automatic tube compensation effort*
Proportional-assist ventilation
Neurally adjusted ventilatory assist

No

Control variable
is
time*

*Example:
Interpulmonary percussive ventilation
FIGURE 2-11 Algorithm for determining the control variable when classifying a mode. SIMV, synchronized intermittent mandatory ventilation.
(Copyright 2011 by Mandu Press Ltd. and reproduced with permission.)

VENTILATOR ALARM SYSTEMS MacIntyre33 has suggested that alarms also be catego-
rized by the events that they are designed to detect. Level
As with other components of ventilation systems, ventilator 1 events include life-threatening situations, such as loss
alarms have increased in number and complexity. Fortu- of input power or ventilator malfunction (e.g., excessive
nately, the classification system I have been describing can or no flow of gas to the patient). The alarms in this cat-
be expanded to include alarms as well (see Table 2-1). egory should be mandatory (i.e., not subject to operator
 Chapter 2 Classification of Mechanical Ventilators and Modes of Ventilation 59

Patient trigger variables Trigger = Start Inspiration

- Airway pressure change Cycle = Stop Inspiration
- Inspiratory or expiratory flow change
Review list of - Bioelectrical signal CMV = Continuous Mandatory Ventilation
operator-initiated - Other signal of patient effort IMV = Intermittent Mandatory Ventilation
Evaluate ventilator Patient cycle variables CSV = Continuous Spontaneous Ventilation
settings and
specifications - Airway pressure change APRV = Airway Pressure Release Ventilation
ventilator-initiated
settings - Inspiratory flow change SIMV = Synchronized Intermittent Mandatory
- Bioelectrical signal Ventilation
- Other signal of patient effort HFV = High-Frequency Ventilation
Machine trigger variables Pmus = Ventilatory Muscle Pressure
Identify what - Time (Preset frequency) R = Resistance
happens - Minute ventilation C = Compliance
during a single - Other machine signal independent of patient mechanics (Pmus, R, C)
breath Machine cycle variables
- Time (Preset inspiratory time)
- Volume
- Other machine signal independent of patient mechanics (Pmus, R, C)

Patient Spontaneous Breath

can trigger No breath is not sequence is
inspiration possible CMV

Yes

Patient
can cycle No No
inspiration*
*Normal operation
not alarm condition
Spontaneous
Yes breaths between Yes
mandatory*
*Example
Spontaneous - SIMV
breath is possible
No

Machine trigger Mandatory Unrestricted

Yes spontaneous
possible breath is possible
breathing*
*Examples
- APRV
No - HFV
Yes

Mandatory Breath
Machine cycle
breath is not No Yes sequence is
possible*
possible IMV
*Normal operation
not safety backup feature
Breath
sequence is
CSV

Record breath
sequence

FIGURE 2-12 Algorithm for determining the breath sequence when classifying a mode. (Copyright 2011 by Mandu Press Ltd. and reproduced with
permission.)
 60

TABLE 2-4: EXPLANATION OF HOW TARGETING SCHEMES TRANSFORM OPERATOR INPUTS INTO VENTILATOR OUTPUTS

Predetermined Inputs Ventilator Output

Control Target
# Variable Scheme Explanation Example Mode Name WB Target Cycle BB Target + Impedance − Impedance
Part II

1 P Set-point Peak airway pressure is PC SIMV P T P

independent of impedance
F
2 P Set-point Peak airway pressure is Pressure support P F
independent of impedance

3 P Set-point Peak airway pressure is Automatic resuscitator F P

independent of impedance

4 V Set-point Tidal volume is independent VC A/C F T

of impedance

5 P Dual P-F Same as #1 if secondary target VAPS P ,F V

not activated
Physical Basis of Mechanical Ventilation

6 V Dual F-P Same as #4 if secondary CMV + Pressure F ,P V

target not activated Limited
7 P Servo Pressure is automatically Percent F
proportional to inspiratory effort Support
Effort is represented by patient:
flow ATC
volume and flow PAV+
8 P Servo Pressure is authomatically NAVA cm H2O NA
proportional to inspiratory effort µv
represented by diaphgram EMG Edi Edi

9 P Adaptive Same as #1 within a breath plus PRVC NA T Volume

volume target between breaths

10 P Optimal Same as #9 plus algorithm to ASV NA F %MV

minimize inspiratory work rate Frequency
Volume
11 P Intelligent Same as #9 plus volume, PCO2 and Smart Care/PS NA NA Frequency
frequency targets using artificial Volume
intelligence algorithms PETCO2

P, pressure; V, volume; F, flow; T, time; R, resistance; E, elastance; MV, minute volume; Edi, electrical activity of diaphragm; low impedance, low resistance and/or elastance;
WB Target, within-breath preset parameters of the pressure, volume, or flow waveform; BB Target, between breath targets modify high impedance, high resistance and/or elastance;
WB targets or overal ventiltory pattern; Cycle, end of inspiration; NA, not available as operator preset, ventilator
determines value if applicable.
Source: Copyright 2011 by Mandu Press Ltd, and reproduced with permission.
 Chapter 2 Classification of Mechanical Ventilators and Modes of Ventilation 61

TABLE 2-5: SPREADSHEET EXAMPLE OF HOW MODES ON TWO COMMON ICU

VENTILATORS WOULD BE CLASSIFIED
The spreadsheet could be sorted any number of ways (e.g., using AutoFilter drop-down dialogs) to compare the ventilators on various capabilities
(e.g., all modes with adaptive pressure targeting). The spreadsheet also functions as a mode translator, giving the different proprietary names for
identical modes.
Order Family Genus Species
Primary Secondary
Breath Breath
Primary
Manufacturer’s Control Breath Target Target
Manufacturer Model Mode Name Variable Sequence Scheme Scheme
Covidien 840 Volume Control Plus Assist Control Pressure CMV adaptive N/A
Covidien 840 Volume Support Pressure CSV adaptive N/A
Covidien 840 Volume Control Plus Pressure IMV adaptive set-point
Synchronized Intermittent
Mandatory Ventilation
Covidien 840 Volume Ventilation Plus Pressure IMV adaptive adaptive
Synchronized Intermittent
Mandatory Ventilation
Covidien 840 Tube Compensation Pressure CSV servo N/A
Covidien 840 Proportional Assist Plus Pressure CSV servo N/A
Covidien 840 Pressure Control Assist Control Pressure CMV set-point N/A
Covidien 840 Pressure Support Pressure CSV set-point N/A
Covidien 840 Spontaneous Pressure CSV set-point N/A
Covidien 840 Pressure Control Synchronized Pressure IMV set-point set-point
Intermittent Mandatory
Ventilation
Covidien 840 BiLevel Pressure IMV set-point set-point
Covidien 840 Volume Control/Assist Control Volume CMV set-point N/A
Covidien 840 Volume Control Synchronized Volume IMV set-point set-point
Intermittent Mandatory
Ventilation
Dräger Evita XL Mandatory Minute Volume with Pressure IMV adaptive set-point
AutoFlow
Dräger Evita XL Continuous Mandatory Ventilation Pressure CMV adaptive N/A
with AutoFlow
Dräger Evita XL Synchronized Intermittent Pressure IMV adaptive set-point
Mandatory Ventilation with
AutoFlow
Dräger Evita XL SmartCare Pressure CSV intelligent N/A
Dräger Evita XL Automatic Tube Compensation Pressure CSV servo N/A
Dräger Evita XL Pressure Controlled Ventilation Pressure CMV set-point set-point
Plus Assisted
Dräger Evita XL Pressure Controlled Ventilation Pressure IMV set-point set-point
Plus Pressure Support
Dräger Evita XL Airway Pressure Release Ventilation Pressure IMV set-point set-point
Dräger Evita XL Continuous Positive Airway Pressure CSV set-point N/A
Pressure/Pressure Support
Dräger Evita XL Mandatory Minute Volume Volume IMV adaptive set-point
Dräger Evita XL Continuous Mandatory Ventilation Volume CMV dual N/A
with Pressure Limited Ventilation
Dräger Evita XL Synchronized Intermittent Volume IMV dual set-point
Mandatory Ventilation with
Pressure Limited Ventilation
Dräger Evita XL Mandatory Minute Volume with Volume IMV dual/ set-point
Pressure Limited Ventilation adaptive
Dräger Evita XL Continuous Mandatory Ventilation Volume CMV set-point N/A
Dräger Evita XL Synchronized Intermittent Volume IMV set-point set-point
Mandatory Ventilation

CMV, continuous mandatory ventilation; CSV, continuous spontaneous ventilation; IMV, intermittent mandatory ventilation.
Source: Copyright 2011 by Mandu Press Ltd. and reproduced with permission.
62 Part II Physical Basis of Mechanical Ventilation

choice), redundant (i.e., multiple sensors and circuits), difficult. It is like buying a Ferrari and putting wooden
and noncanceling (i.e., alarm continues to be activated, wheels on it. In the future, water vapor should be treated
even if the event is corrected, and must be reset manu- like any other desirable inhaled gas constituent (e.g., air,
ally). Level 2 events can lead to life-threatening situations oxygen, helium, or nitric oxide) and metered from within
if not corrected in a timely fashion. These events include the ventilator. The inspiratory part of the patient circuit
such things as blender failure, high or low airway pressure, should be a sterile, insulated, permanent part of the ven-
autotriggering, and partial patient circuit occlusion. They tilator right up to the patient connection, which can be a
also may include suspicious ventilator settings such as an disposable tip for cleaning purposes. The gas should be
inspiratory-to-expiratory timing (I:E) ratio greater than delivered under high pressure as a jet to provide not only
1:1. Alarms for level 2 events may not be redundant and conventional pressure, volume, and flow waveforms but
may be self-canceling (i.e., alarm inactivated if event ceases also high-frequency ventilation. The jet also can be used
to occur). Level 3 events are those that affect the patient– to provide a counterflow PEEP effect, eliminating any
ventilator interface and may influence the level of support need for an exhalation–valve system. The disposable tip
provided. Examples of such events are changes in patient could be designed to house disposable sensors and would
compliance and resistance, changes in patient respiratory be the only part of the circuit to be exposed to the patient’s
drive, and auto-PEEP. Alarm function at this level is similar exhaled gas. If ventilator manufacturers saw themselves as
to that of level 2 alarms. Level 4 events reflect the patient providers of the entire system, instead of letting third par-
condition alone rather than ventilator function. As such, ties deal in plastic connecting tubing, I think we would see
these events usually are detected by stand-alone monitors, a huge evolutionary step in ventilator performance, better
such as oximeters, cardiac monitors, and blood-gas ana- patient outcomes, and potential savings in labor costs for
lyzers. Some ventilators, however, are able to incorporate providers.
the readings of a capnograph in their displays and alarm Third, the most exciting area for development probably
systems. is in the intelligence that will be built into future ventila-
tor control circuits. The real challenge in closed-loop con-
trol of ventilation is defining, measuring, and interpreting
the appropriate feedback signals. If we stop to consider
THE FUTURE all the variables a human operator assesses, the problem
looks insurmountable. Not only does a human consider a
Almost 20 years ago, Warren Sanborn predicted that ventilators wide range of individual physiologic variables, but there
today would “… report the patient’s metabolic state; manage are the more abstract evaluations of such things as meta-
oxygen delivery; calculate cardiac output, synchronize breath bolic, cardiovascular, and psychological states. Add to this
delivery with cardiac cycle to maximize cardiac output…and the various environmental factors that may affect opera-
perform all these functions automatically or at least presenting tor judgment, and we get a truly complex control problem
consensus-based advisory messages to the practitioner….”17 (Fig. 2-13).
Some of these ideas were never developed commercially. I would like to speculate now about a response to this
Some were tried and abandoned. Some, have evolved beyond challenge. The ideal control strategy would have to start out
Warren’s broad vision. with basic tactical control of the individual breath. Next, we
There are three basic ways to improve ventilators in the add longer-term strategic control that adapts to changing
future. First, just like computer games, ventilators need to load characteristics. Mathematical models could provide the
improve the operator interface constantly. Yet very little basic parameters of the mode, whereas expert rules would
research has been done to call attention to problems with place limits to ensure lung protection.
current displays.34,35 We have come a long way from using a Next, we sample various physiologic parameters and use
crank to adjust the stroke of a ventilator’s piston to set tidal fuzzy logic to establish the patient’s immediate condition.
volume. The operator interface must provide for three basic This information is passed on to a neural network, which
functions: allow input of control and alarm parameters, would then select the best response to the patient’s condition.
monitor the ventilator’s status, and monitor the ventilator– The neural network ideally would have access to a huge
patient interaction status. We have a long way to go before database comprised of both human expert rules and actual
the user interface provides an ideal experience with these patient responses to various ventilator strategies. This
functions. arrangement would allow the ventilator not only to learn
Second, the weak link in the patient–ventilator system from its interaction with the current patient but also to con-
is the patient circuit. We buy a $35,000 ventilator with tribute to the database.
state-of-the-art computer control, and then we connect it Finally, the database and this ventilator could be net-
to the patient (priceless) with a $1.98 piece of plastic tub- worked with other intelligent ventilators to multiply the
ing that is subject to filling with condensate from a heated learning capacity exponentially (Fig. 2-14). Whatever
humidifier whose design has not changed appreciably the future brings, it seems clear that ventilators will have
in 20 years. The resistance and compliance of the deliv- more intelligence built in to increase patient safety and
ery circuit make flow control and volume delivery more decrease the time required to provide care.
 Chapter 2 Classification of Mechanical Ventilators and Modes of Ventilation 63

Set-point
Adjustment

Pressure
Volume
Flow
Pressure Resp rate
Environment
(PIP and PEEP) Heart rate
Volume PeCO2
Frequency PaO2
Time FiO2 FiO2
Cost SpO2
Triage priority P0.1
Experience Disturbances

Alarms
Operator Ventilator Patient

Flow
Pressure

Bronchospasm Metabolic state

Underlying disease Acid–base state
Strength/Endurance Cardiovascular state
Neural control Psychological state
Auto-PEEP Drugs
FIGURE 2-13 The challenge of total computer control of mechanical ventilation. Solid arrows depict signals that have been used at least experimen-
tally. Dotted arrows represent potential feedback signals. (Reproduced, with permission, from Chatburn RL. Computer control of mechanical ventila-
tion. Respir Care. 2004;49:507–515.)

Human
experts
Optimization
models
Strategic
Competitive control
Registry neural
Database network Intelligent Expert
Prior Determine control rules
experience best
rules Disturbances

Ventilator Patient

Networked ventilators Flow

Tactical control
Pressure

Fuzzy
logic
Determine
patient
condition

FIGURE 2-14 A potential approach to the challenge of fully automated control of mechanical ventilation. (Reproduced, with permission, from
Chatburn RL. Computer control of mechanical ventilation. Respir Care. 2004;49:507–515.)
64 Part II Physical Basis of Mechanical Ventilation

SUMMARY AND CONCLUSION 11. Desautels DA. Ventilator performance. In: Kirby RR, Smith RA,
Desautels DA, eds. Mechanical Ventilation. New York, NY: Churchill
Livingstone; 1985:120.
Mechanical ventilators have become so complex that a 12. Sassoon CSH, Girion AE, Ely EA, Light RW. Inspiratory work of
system of classification is necessary to communicate intel- breathing on flow-by and demand flow continuous positive airway
pressure. Crit Care Med. 1989;17:1108–1114.
ligently about them. The theoretical basis for this classifica- 13. Amato MB, Barbas CS, Bonassa J, et al. Volume-assured pres-
tion system is a mathematical model of patient–ventilator sure support ventilation (VAPS): a new approach for reducing
interaction known as the equation of motion for the respira- muscle workload during acute respiratory failure. Chest. 1992;102:
tory system. From this model we deduce that as far as an 1225–1234.
14. Younes M. Proportional assist ventilation, a new approach to ventila-
individual inspiration is concerned, any conceivable venti- tor support: I. Theory. Am Rev Respir Dis. 1992;145:114–120.
lator can be classified as either a pressure, volume, or flow 15. Guttmann J, Eberhard L, Fabry B, et al. Continuous calculation of
controller (and in rare cases, simply an inspiratory-expira- intratracheal pressure in tracheally intubated patients. Anesthesiology.
1993;79(3):503–513.
tory time controller). An individual breath is shaped by the 16. Sinderby C, Beck J, Spahija J, et al. Inspiratory muscle unloading by
phase variables that determine how the breath is triggered neurally adjusted ventilatory assist during maximal inspiratory efforts
(started), targeted (sustained), and cycled (stopped). in healthy subjects. Chest. 2007;131(3):711–717.
A mode of ventilation can be characterized using a four- 17. Sanborn WG. Microprocessor-based mechanical ventilation. Respir
Care. 1993;38(1):72–109.
level taxonomy: (a) control variable, that is, pressure or vol- 18. Stengel RF. Optimal Control and Estimation. Mineola, NY: Dover Pub-
ume according to the equation of motion; (b) the breath lications, 1994.
sequence, that is, CMV, IMV, or CSV; (c) targeting scheme 19. Tehrani FT. Automatic control of an artificial respirator. Conf Proc
for primary breaths; and (d) targeting scheme for second- IEEE Eng Med Biol Soc. 1991;13:1738–1739.
20. Tehrani FT. Automatic control of mechanical ventilation, Part 2:
ary breaths. The trend in ventilator targeting schemes The existing techniques and future trends. J Clin Monit Comput.
has been from basic manual control (within-breath con- 2008;22(6):417–424.
trol requiring operator input of static set-points), to more 21. Otis AB, Fenn WO, Rahn H. Mechanics of breathing in man. J Appl
Physiol. 1950;2:592–607.
advanced automatic control (between-breath control of set- 22. Intelligent control. http://en.wikipedia.org/wiki/Intelligent_control.
points that are adjusted automatically by the ventilator with Last modified October 10, 2011. Last accessed April 30, 2010.
minimal operator input), to the highest level of intelligent 23. East TD, Heermann LK, Bradshaw RL, et al. Efficacy of computerized
control (in which the operator theoretically may be elimi- decision support for mechanical ventilation: results of a prospective
multicenter randomized trial. Proc AMIA Symp. 1999;251–255.
nated altogether in favor of artificial-intelligence systems 24. Lellouche F, Mancebo J, Jolliet P, et al. A multicenter randomized trial
capable of learning). of computer-driven protocolized weaning from mechanical ventila-
tion. Am J Respir Crit Care Med. 2006;174(8):894–900.
25. Rose L, Presneill JJ, Cade JF. Update in computer-driven weaning from
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26. Rose L, Presneill JL, Johnston L, Cade JF. A randomised, controlled
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Respir Med. 2010;4(6):809–819. 28. Gottschalk A, Hyzer MC, Greet RT. A comparison of human and
3. Chatburn RL, Volsko TA. Mechanical ventilators. In: Wilkins RL, machine-based predictions of successful weaning from mechanical
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ratory Care: Principles and Practice. Philadelphia, PA: Saunders; marek RM, eds. Egan’s Fundamentals of Respiratory Care. 10th ed. St.
2002:757–809. Louis, MO: Mosby Elsevier; 2011 (in press).
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BASIC PRINCIPLES 3
OF VENTILATOR DESIGN
Robert L. Chatburn
Eduardo Mireles-Cabodevila

THE VENTILATOR AS A “BLACK BOX” Baseline Variables

Inputs Positive End-Expiratory Pressure
Conversion and Control Alarms
Outputs VENTILATOR OUTPUTS (DISPLAYS)
THE OPERATOR INTERFACE Display Types
Operator Inputs THE FUTURE
Inspired Gas Concentration Better Operator Interfaces
Trigger Variables Better Patient Interfaces
Target Variables Better Targeting Systems
Cycle Variables

THE VENTILATOR AS A “BLACK BOX” There was a time when you could take a handful of
simple tools and do routine maintenance on your car engine.
A mechanical ventilator is an automatic machine designed to About that time the average clinician could also completely
provide all or part of the work the body must do to move gas disassemble and reassemble a mechanical ventilator as a
into and out of the lungs. The act of moving air into and out training exercise or to perform repairs. In those days (the
of the lungs is called breathing, or, more formally, ventilation. late 1970s), textbooks1 describing ventilators understand-
The simplest mechanical device we could devise to assist ably paid much attention to the individual mechanical
a person’s breathing would be a hand-driven, syringe-type components and pneumatic schematics. In fact, this philoso-
pump that is fitted to the person’s mouth and nose using phy was reflected to some extent in previous editions of this
a mask. A variation of this is the self-inflating, elastic book. Today, both cars and ventilators are incredibly complex
resuscitation bag. Both of these require one-way valve mechanical devices controlled by multiple microprocessors
arrangements to cause air to flow from the device into running sophisticated software (Fig. 3-1). Figure 3-2 shows
the lungs when the device is compressed, and out from the pneumatic schematic of a current intensive care ventila-
the lungs to the atmosphere as the device is expanded. These tor. All but the most rudimentary maintenance of ventilators
arrangements are not automatic, requiring an operator to is now the responsibility of specially trained biomedical
supply the energy to push the gas into the lungs through engineers. Our approach to describing ventilator design has
the mouth and nose. Thus, such devices are not considered thus changed from a focus on individual components to
mechanical ventilators. a more generalized model of a ventilator as a “black box,”
Automating the ventilator so that continual opera- that is, a device for which we supply an input and expect
tor intervention is not needed for safe, desired operation a certain output and whose internal operations are largely
requires three basic components: unknowable, indeed, irrelevant, to most clinical operators.
What follows, then, is only a brief overview of the key design
1. A source of input energy to drive the device; features of mechanical ventilators with an emphasis on input
2. A means of converting input energy into output energy in power requirements, transfer functions (pneumatic and
the form of pressure and flow to regulate the timing and electronic control systems), and outputs (pressure, volume,
size of breaths; and and flow waveforms). The rest of the chapter focuses on
3. A means of monitoring the output performance of the the interactions between the operator and the ventilator
device and the condition of the patient.

65
66 Part II Physical Basis of Mechanical Ventilation

A B

C D
FIGURE 3-1 Examples of commonly used intensive care ventilators: A. Dräger Infinity V500, B. Hamilton G5, C. Maquet Servo i,
D. Covidien PB840. (Image with permission from Nellcor Puritan Bennett LLC, Boulder, Colorado, doing business with Covidien.)
 Chapter 3 Basic Principles of Ventilator Design 67

A 8 B 9 10 11

3 7
5 P 18 F
17 E
27 28
4 6 P .
Co2 V
E 12
20 E E
2 19

13

23 24 G C 14
Air
26 O2
H E D . Insp. gas
25 21 O2 P V
I E E 16 15 E Exp. gas
22 Nebulizer gas

1 Air gas inlet 16 Barometric pressure sensor

2 O2 gas inlet 17 Calibration valve for inspiratory pressure sensor
3 Air nonreturn valve 18 Inspiratory pressure sensor
4 O2 nonreturn valve 19 Calibration valve for expiratory pressure sensor
5 Air metering valve 20 Expiratory pressure sensor
6 O2 metering valve 21 O2 sensor
7 Tank 22 Nebulizer outlet
8 Mixed gas metering valve 23 Air pressure regulator
9 Safety valve 24 O2 pressure regulator
10 Emergency expiratory valve 25 Nebulizer mixer valve
11 Emergency breathing valve 26 Nebulizer changeover valve
12 Patient’s lungs 27 CO2 sensor
13 Expiratory valve 28 Neonatal flow sensor (depending on the patient category)
14 Nonreturn valve
15 Expiratory flow sensor
FIGURE 3-2 Pneumatic schematic of the Dräger Infinity V500 intensive care ventilator. A. Gas-mixture and gas-metering assembly. Gas from the
supply lines enters the ventilator via the gas-inlet connections for oxygen and air (1,2). Two nonreturn valves (3,4) prevent one gas from returning
to the supply line of the other gas. Mixing takes place in the tank (7) and is controlled by two valves (5,6). Inspiratory flow is controlled by a third
valve (8). B. Inspiratory unit consists of safety valve (9) and two nonreturn valves (10,11). In normal operation, the safety valve is closed so that
inspiratory flow is supplied to the patient’s lungs (12). During standby, the safety valve is open and enables spontaneous inspiration by the emer-
gency breathing valve (11). The emergency expiratory valve (10) provides a second channel for expiration when the expiratory valve (13) is blocked.
C. Expiratory unit consists of the expiratory valve (13) and a nonreturn valve (14). The expiratory valve is a proportional valve and is used to adjust
the pressure in the patient circuit. In conjunction with the spring-loaded valve of the emergency air outlet (10), the nonreturn valve (14) prevents pen-
dulum breathing during spontaneous breathing. D. Expiratory flow sensor. E. Barometric pressure sensor. Conversion of mass flow to volume, body
temperature and pressure saturated (BTPS) requires knowledge of ambient pressure. F. Pressure measurement assembly. Pressure in the patient circuit
is measured with two independent pressure sensors (18,20). G. Calibration assembly. The pressure sensors are regularly zero calibrated by connection
to ambient pressure via the two calibration valves (17,19). H. Oxygen sensor. I. Medication nebulizer assembly. (Reproduced, with permission, from
Dräger Medical AG & Co. KG. V500 Operator’s Manual. Luebeck, Germany.)
68 Part II Physical Basis of Mechanical Ventilation

(the operator interface), and between the ventilator and the

patient (the patient interface).

Inputs
Mechanical ventilators are typically powered by electricity
or compressed gas. Electricity, either from wall outlets
(e.g., 100 to 240 volts AC, at 50/60 Hz) or from batteries
(e.g., 10 to 30 volts DC), is used to run compressors of
various types. Batteries are commonly used as the primary
power source in the home-care environment but are
usually reserved for patient transport or emergency use
in hospitals. These sources provide compressed air for
motive power as well as air for breathing. Alternatively, the
power to expand the lungs is supplied by compressed gas
from tanks, or from wall outlets in the hospital (e.g., 30 to
80 pounds per square inch [psi]). Some transport and emer-
gency ventilators use compressed gas to power both lung
inflation and the control circuitry. For these ventilators,
knowledge of gas consumption is critical when using
cylinders of compressed gas.
The ventilator is generally connected to separate sources
of compressed air and compressed oxygen. In the United
States, hospital wall outlets supply air and oxygen at 50 psi,
although most ventilators have internal regulators to reduce
this pressure to a lower level (e.g., 20 psi). This permits the
delivery of a range of oxygen concentrations to support
FIGURE 3-3 CareFusion Infant Flow SiPAP device.
the needs of sick patients. Because compressed gas has all
moisture removed, the gas delivered to the patient must be
warmed and humidified so as to avoid drying out the lung
tissue. tubing that conducts the gas to the patient, called the patient
circuit. Such devices are used in small transport ventilators
Conversion and Control and automatic resuscitators. Manually adjusted variable-
orifice flow meters have been used in simple infant ventila-
The input power of a ventilator must be converted to a tors in the past (e.g., Bourns BP-200) and are currently used
predefined output of pressure and flow. There are several in the Infant Flow SiPAP device (CareFusion, Minneapolis,
key systems required for this process. If the only power MN), as shown in Figure 3-3. The advent of inexpensive
input is electrical, the ventilator must use a compressor microprocessors in the 1980s led to development of digital
or blower to generate the required pressure and flow. A control of flow valves that allow a great deal of flexibility in
compressor is a machine for moving a relatively low flow shaping the ventilator’s output pressure, volume, and flow
of gas to a storage container at a higher level of pressure waveforms (Fig 3-4).2 Such valves are used in most of the
(e.g., 20 psi). A blower is a machine for generating rela- current generation of intensive care ventilators.
tively larger flows of gas as the direct ventilator output Directing flow from the source gas into the patient
with a relatively moderate increase of pressure (e.g., 2 psi). requires the coordination of the output flow-control valve
Compressors are generally found on intensive care ventila- and an expiratory valve or “exhalation manifold” (Fig. 3-5).
tors whereas blowers are used on home-care and transport In the simplest case, when inspiration is triggered on, the
ventilators. Compressors are typically larger and consume output control valve opens, the expiratory valve closes, and
more electrical power than blowers, hence the use of the the only path left for gas is into the patient. When inspira-
latter on small, portable devices. tion is cycled off, the output valve closes and the exhalation
valve opens, flow from the ventilator ceases and the patient
exhales out through the expiratory valve (see Fig. 3-2). The
FLOW-CONTROL VALVES
most sophisticated ventilators employ a complex interaction
To control the flow of gas from a compressor, ventilator engi- between the output flow-control valve and the exhalation
neers use a variety of flow-control valves, from very simple valve, such that a wide variety of pressure, volume, and flow
to very complex. The simplest valve is just a fixed orifice flow waveforms may be generated to synchronize the ventilator
resistor that permits setting a constant flow to the external output with patient effort as much as possible.
 Chapter 3 Basic Principles of Ventilator Design 69

Wires to
controller

Coils

Actuator

the fluidic circuit uses a very small gas flows to generate

signals that operate switches and timing components.
Both pneumatic and fluidic control systems are immune to
failure from electromagnetic interference, such as around
magnetic resonance imaging equipment. Examples of
simple pneumatic and fluidic ventilator control circuits
have been illustrated elsewhere.5 By far, the majority of ven-
tilators use electronic control circuits with microprocessors
to manage the complex monitoring (e.g., from pressure and
flow sensors) and control (valves) functions of modern
ventilators used in almost every health care environment.
What makes one ventilator so different from another has
as much to do with the control system software as it does
with the hardware. The control software determines how
the ventilator interacts with the patient; that is, the modes
available. Thus, a discussion about control systems is essen-
tially a discussion about mode capabilities and classifica-
tions. Chapter 2 describes the specific design principles of
ventilator control systems in detail.

Outputs
Just as the study of cardiology involves the use of electro-
cardiograms and blood pressure waveforms, the study
of mechanical ventilation requires an understanding of
output waveforms. The waveforms of interest are the
pressure, volume, and flow.

IDEALIZED PRESSURE, VOLUME,

AND FLOW WAVEFORMS
Output waveforms are conveniently graphed in groups of
three. The horizontal axis of all three graphs is the same
and has the units of time. The vertical axes are in units of
pressure, volume, and flow. For the purpose of identifying
70 Part II Physical Basis of Mechanical Ventilation

characteristic waveform shapes, the specific baseline EFFECTS OF THE PATIENT CIRCUIT
values are irrelevant. What is important is the relative
The pressure, volume, and flow the patient actually
magnitudes of each of the variables and how the value of
receives are never precisely the same as what the clini-
one affects or is affected by the value of the others.
cian sets on the ventilator. Sometimes these differences
Figure 3-7 illustrates the typical waveforms available on
are caused by instrument inaccuracies or calibration error.
modern ventilators. These waveforms are idealized; that is,
More commonly, the patient delivery circuit contributes
they are precisely defined by mathematical equations and are
to discrepancies between the desired and actual patient
meant to characterize the operation of the ventilator’s con-
values. This is so because the patient circuit has its own
trol system. As such, they do not show the minor deviations,
compliance and resistance. Thus, the pressure measured
or “noise,” often seen in waveforms recorded during actual
inside a ventilator upstream of the patient always will be
ventilator use. This noise can be caused by a variety of
higher than the pressure at the airway opening because
extraneous factors such as vibration and flow turbulence. Of
of patient circuit resistance. In addition, the volume and
course, scaling of the horizontal and vertical axes can affect
flow coming out of the ventilator’s exhalation manifold
the appearance of actual waveforms considerably. Finally,
will exceed those delivered to the patient because of the
the waveforms in Figure 3-7 do not show the effects of the
compliance of the patient circuit.
resistance and compliance of the patient circuit.
Exactly how the mechanical properties of the patient
No ventilator is an ideal pressure, volume, or flow
circuit affect ventilator performance depends on whether
controller, and ventilators are designed to only approximate
they are connected in series or in parallel with the patient.
a particular waveform. Idealized waveforms as shown in
It turns out that the resistance of the patient circuit is
Figure 3-7 are, nevertheless, helpful because they are used
connected in series whereas the compliance is modeled as
commonly in other fields (e.g., electrical engineering),
a parallel connection. To understand this, we first make the
which makes it possible to use mathematical procedures
simplifying assumption that we can examine the patient cir-
and terminology that already have been established. For
cuit’s resistance separate from its compliance. It is intuitively
example, a standard mathematical equation is used to
obvious that the same flow of gas that comes from the ven-
describe the most common ventilator waveforms for each
tilator travels through the circuit tubing as through the
control variable. This known equation may be substituted
patient’s airway opening. We also can see that the pressure
into the equation of motion, which is then solved to get the
drop across the patient circuit will be different from that
equations for the other two variables. Once the equations
across the respiratory system because they have different
for pressure, volume, and flow are known, they are easily
resistances. By a definition we borrow from electronics,
graphed. This is the procedure that was used to generate the
when two circuit components share the same flow but have
graphs in Figure 3-7.
different pressure drops, they are connected in series. This

A B C D E
Pressure
Volume

Inspiration
Flow

Expiration

FIGURE 3-7 Idealized ventilator output waveforms. A. Pressure-controlled inspiration with a rectangular pressure waveform. B. Volume-controlled
inspiration with a rectangular flow waveform. C. Volume-controlled inspiration with an ascending-ramp flow waveform. D. Volume-controlled inspi-
ration with a descending-ramp flow waveform. E. Volume-controlled inspiration with a sinusoidal flow waveform. The short dashed lines represent
mean inspiratory pressure, and the long dashed lines represent mean pressure for the complete respiratory cycle (i.e., mean airway pressure). Note that
mean inspiratory pressure is the same as the pressure target in A. These waveforms were created as follows: (a) defining the control waveform using a
mathematical equation (e.g., an ascending-ramp flow waveform is specified as flow = constant × time), (b) specifying the tidal volume for flow-control
and volume-control waveforms, (c) specifying the resistance and compliance, (d) substituting the preceding information into the equation of motion
for the respiratory system, and (e) using a computer to solve the equation for the unknown variables and plotting the results against time. (Reproduced,
with permission, from Chatburn RL. Fundamentals of Mechanical Ventilation. Cleveland Heights, OH: Mandu Press; 2003:143.)
 Chapter 3 Basic Principles of Ventilator Design 71

means that the patient circuit resistance, however small, adds We can get a more intuitive understanding of this equa-
to the total resistive load seen by the ventilator. Thus, in a tion if we put in some values. Suppose, for example, that
volume-controlled breath, the peak inspiratory pressure is we use the perfect patient circuit that has zero compliance.
higher, and in a pressure-controlled breath, the tidal volume Substituting zero for CPC, we get
and peak flow are lower. In practice, the effect of patient
Vset Vset
circuit resistance is usually ignored because it is so much Vdelivered = =
lower than the resistance of the respiratory system. 1 + (C PC /C RS ) 1 + (0/C RS )
(2)
Now consider the patient circuit compliance. The V V
effective compliance of the patient circuit is a com- = set = set = Vset
1+ 0 1
bination of the tubing compliance and the compress-
ibility of the gas inside it. As the ventilator delivers the which shows that there is no effect on the delivered tidal vol-
breath to the patient, pressure at the airway opening ume. Suppose now that CPC is as large as CRS (i.e., CPC = CRS).
rises relative to atmospheric pressure, which is the driv- Now we have
ing force for flow into the lungs. The patient circuit is
connected between the ventilator and the airway, so the Vset V V
Vdelivered = = set = set (3)
pressure it experiences across its walls is the same as that 1 + (C PC /C RS ) 1+ 1 2
experienced by the respiratory system (remember that
we are ignoring its resistance now, so we can ignore any in which case, half the volume from the ventilator goes to
pressure drop between the ventilator outlet and the air- the patient, and the other half is compressed in the patient
way opening). The volume change of the patient circuit circuit. Some ventilators automatically compensate for gas
tubing is different from that of the respiratory system lost to the patient circuit.2
because the compliance of the circuit is different. Because The effect of the patient circuit is more troublesome
the patient circuit and the respiratory system fill with during volume-controlled modes than during pressure-
different volumes during the same inspiratory time, the controlled modes. This is so because during volume control,
flows they experience are different (remember that flow = the ventilator meters out a specific volume of gas, and unless
volume ÷ time). Again borrowing a definition from elec- it measures flow at the airway opening, it has no way of
tronics, if two circuit components share the same pressure knowing how much goes to the patient and how much goes
drop but different flows, they are connected in paral- to the patient circuit. In contrast, during pressure-controlled
lel. Because they are in parallel, the two compliances are modes, the ventilator simply meters out a set pressure change
additive, so the total compliance is greater than either no matter where the gas goes. Because the respiratory system
component. and the patient circuit compliance are in parallel, they both
Patient circuit compliance sometimes can be greater than experience the same driving pressure (peak inspiratory
respiratory system compliance and thus can have a large pressure minus end-expiratory pressure), so tidal volume
effect on ventilation. It must be accounted for either auto- delivery is affected very little. The only effect might be that
matically by the ventilator or manually by increasing the tidal the patient circuit compliance may tend to increase the pres-
volume. For example, when ventilating neonates, patient sure rise time, which would tend to decrease peak flow and
circuit compliance can be as much as three times that of the tidal volume slightly.
respiratory system, even with small-bore tubing and a small- Another area where patient circuit compliance causes
volume humidifier. Thus, when trying to deliver a preset trouble is in the determination of auto-PEEP. There are
tidal volume during volume-controlled ventilation, as little several methods for determining auto-PEEP. One method
as 25% of the set volume will be delivered to the patient, with to determine auto-PEEP during mechanical ventilation is
75% compressed in the patient circuit. The compliance of the to create an expiratory hold manually (i.e., delay the next
patient circuit can be determined by occluding the tubing at inspiration) until static conditions prevail throughout the
the patient Y, delivering a small volume under flow control lungs (i.e., no flow anywhere in the lungs). The pressure
(using zero positive end-expiratory pressure [PEEP]), and at this time (total PEEP) minus the applied PEEP is an
noting the resulting pressure. Using a short inspiratory hold estimation of global auto-PEEP. Note that auto-PEEP may
will make it easier to read the pressure. Then compliance vary throughout the lungs depending on the distribution of
is calculated as before, by dividing the volume by the pres- lung disease and may not reflect pressure behind collapsed
sure. Once the patient circuit compliance is known, the set areas in patients with severe flow limitation. Auto-PEEP is
tidal volume can be corrected using the following equation: an index of the gas trapped in the system at end expiration
secondary to an insufficient expiratory time:
Vset
Vdelivered = (1) Vtrapped
1 + (C PC / CRS ) measured auto-PEEP = (4)
C total
where Vdelivered is the tidal volume delivered to the patient,
Vset is the tidal volume setting on the ventilator, CPC is the where Vtrapped is the volume of gas trapped in the patient and
patient circuit compliance, and CRS is the respiratory system the patient circuit at end-expiration (above that associated
compliance. with applied PEEP), and Ctotal is the total compliance of the
72 Part II Physical Basis of Mechanical Ventilation

respiratory system and the patient circuit. The problem is

that we want auto-PEEP to reflect the gas trapped in the
patient, not in the circuit. If we know the compliances of the
patient circuit and the respiratory system, we can correct
the measured auto-PEEP as follows:
C RS + C PC
true auto-PEEP = × measured auto-PEEP (5)
C RS

where true auto-PEEP is that which exists in the lungs, mea-

sured auto-PEEP is the amount of end-expiratory pressure in
equilibration with the lungs and the patient circuit, CRS is the
respiratory system compliance, and CPC is the patient circuit
compliance. If the ventilator displays auto-PEEP on its moni-
tor, check the ventilator’s operating manual to see whether or
not the auto-PEEP calculation is corrected for patient circuit
compliance. The larger CPC is relative to CRS, the larger will be
the error. Again, the error will be most noticeable in pediat-
ric and neonatal patients.
FIGURE 3-8 Puritan Bennett LP-10 home-care ventilator. (Image with
permission from Nellcor Puritan Bennett LLC, Boulder, Colorado,
THE OPERATOR INTERFACE doing business with Covidien.)

The operator interaction with the ventilator mainly happens

through the ventilator display. The display or interface Operator Inputs
has evolved in parallel with the ventilators. The key to
this evolution are the technological advances in the last The operator input refers to parameters or settings entered
three decades.2 The microprocessors, the digital displays, by the operator of the ventilator. Each mode of ventilation
and the interactive screens have all permeated from other has particular features, some of which can be adjusted by
technological advances into the ventilator world. There the operator. We describe here the most common adjust-
are still remnants of the evolutionary process. In their ini- able parameters. The effect of each parameter on the lung
tial ventilator generations, the interface had no or minimal is better understood under the light of the equation of
manifestation of the interaction with the patient. The operator motion (see Chapter 2).9,10 A change of one parameter will
would enter the ventilator settings by using knobs or buttons lead to changes in others (i.e., in volume control, for the
that regulated simple functions (pressure, flow, or time). The same respiratory characteristics changing the tidal volume
results of these changes were evaluated in the patient clinical will cause a change in peak airway pressure). Furthermore,
response, and occasionally through simple pressure analog knowing the basic construction and characteristics of a
displays. Some ventilators still use these type of displays (e.g.,
CareFusion 3100A high-frequency oscillator and Puritan
Bennett LP-10, Fig. 3-8).
Most of the ventilators produced in the last decade have
advanced displays, including liquid crystal displays and color
touch screens with one or more multipurpose knobs or
buttons. This allows the user to scroll through different menus
and to select and activate the selections (e.g., Hamilton G5
ventilator, Fig. 3-9). The operator can customize the screen to
the operator’s needs. Current ventilators allow graphical dis-
plays of alarms, settings, respiratory system calculations, and
measurements. The ventilator display evolution has not nec-
essarily resulted in easier management of the ventilator. These
advances brought issues with the amount of information dis-
played, the actions taken with that information, and the ease
of use of certain interfaces.6 As the level of sophistication has
increased, we have been able to increase the number of ven-
tilation parameters monitored. This requires a new level of
training and understanding of human behavior. For example,
a mode of ventilation may be preferentially chosen based on FIGURE 3-9 G5 ventilator. (Reproduced with permission from
the amount of alarms it triggers,7 or its ease of use.6,8 Hamilton Medical, AG.)
 Chapter 3 Basic Principles of Ventilator Design 73

mode of ventilation (volume vs. pressure control breaths) or where O2 required is 100% oxygen flow in L/min, f is the
the breath sequence (mandatory vs. spontaneous) will help breathing frequency in breaths/min, VT is the tidal volume in
understand how the setting will affect the ventilator output liters and the FIO2 is the patient O2 concentration desired in
(see Chapter 2). decimal format (i.e., 30% = 0.3). An oxygen analyzer should
The operator input is presented below in the order be used to confirm the measurements. It must be recognized
that follows the progression of a breath; starting with the that changes in oxygen flow, breathing rate, or tidal volume
gas inhaled, to triggering, targeting, cycling, and baseline will change the FIO2.
variables. When transporting the critically ill patient, availability
of oxygen supplies for the mechanically ventilated patient
is crucial. Size and weight of cylinders makes transport dif-
Inspired Gas Concentration ficult and presents an increased risk of fire. Branson et al.
have described a solution using a portable oxygen concen-
A mechanical ventilator has the capacity of deliver- trator (SeQual Eclipse II) paired with the Impact 754 and
ing different mixtures of gas. Most ventilators allow the Pulmonetics LTV-1200 ventilators.11
administration of specific concentrations of oxygen. A few For the rest of the current mechanical ventilators, the
allow the administration of helium, nitric oxide, or anesthe- ventilator adjusts the mixture of air and oxygen to achieve
sia gases. the desired FIo2. The mixing of air is achieved by an internal
or external blender. A blender may use proportioning valves
OXYGEN that regulate the flow of air and oxygen to a mixing changer
(Fig. 3-10). It is similar to the mechanism used to mix hot
Oxygen is the most common gas administered to patients and cold water in a shower—the more oxygen needed, the
undergoing mechanical ventilation. The oxygen percentage larger the opening for oxygen and the smaller it is for air.
in the inspired gas (FIO2) can be regulated in most ventilators To work properly, the blender requires a constant pressure
by means of a direct adjustment of a specific control (21% to within the working ranges of the device.
100%). However, this is not true for all ventilators. For exam- Most current ventilators have oxygen sensors to moni-
ple, some home ventilators (e.g., LP-10 or the LTV 1150, tor the FIO2. The oxygen sensor gives feedback to the opera-
Pulmonetic, CareFusion) use a connection to a low-pressure tor to adjust the mixture, or alarms if there is a discrepancy
oxygen source to the ventilator or the patient circuit. The between the set and delivered FIO2. The oxygen sensors detect
following formula can calculate the flow of oxygen to achieve changes in electrical current, which is proportional to the
a desired oxygen concentration: oxygen concentration. The most common techniques are:
f × VT × (desired F Io2 − 0.21) (a) paramagnetic, (b) polarographic, and (c) galvanic.12
O2 required = (6)
0.79

Ventilator computer control

(Set FIO2 and tidal volume)

Oxygen Air

Inspiratory mixing chamber

FIO2 and tidal volume delivered

FIGURE 3-10 Schematic of a ventilator air–oxygen blending system using proportional valves.
74 Part II Physical Basis of Mechanical Ventilation

TABLE 3-1: PROPERTIES OF PURE GASES AND AIR

Thermal Conductivity (κ) viscosity (η) Density (ρ)

Gas (µcal · cm · s · °k) (Micropoises) (g/L)

Helium (He) 352.0 188.7 0.1785

Nitrogen (N2) 58.0 167.4 1.251
Oxygen (O2) 58.5 192.6 1.429
Air 58.0 170.8 1.293

HELIOX so far, only one device is approved in the United States.

The INOvent (Ikaria Inc, Clinton, NJ) delivery system
Mixtures of helium and oxygen (heliox, HeO2) instead of
uses a closed-loop scheme to measure and deliver NO in
air and oxygen are occasionally used to help patients on
proportion to the inspiratory flow from the ventilator.
mechanical ventilation with obstructive airway diseases.
NO is injected in the proximal limb of the inspiratory cir-
Helium is less dense than air (Table 3-1).13 The decrease in
cuit, and measured close to the connection between the
density interferes with flow measurements, inspiratory and
patient circuit and the endotracheal tube. Two portable
expiratory valve accuracy, and gas mixing.14 Several studies
systems are available—INO Max DS (Ikaria) and AeroNOx
have evaluated the performance of mechanical ventilators
(PulmoNOx, Alberta, CA). As these devices are not uni-
delivering heliox14–16 and have shown that heliox does affect
versally available, the following formula19 can be used to
the performance of the ventilator. The interference of heliox
calculate the NO flow rate required to achieve a desired
is more evident in volume-control modes than in pressure-
concentration of NO when injected in the inspiratory limb
control modes.14,17 In pressure-control mode, the ventila-
at a constant gas flow,
tor targets a set inspiratory pressure and the delivered tidal
volume is dependent only on the mechanical properties of  CNOset  ×Q
QNO = (7)
the respiratory system. The time constant may decrease but  CNOcyl − CNOset  V
the delivered volume should be the same as for nonheliox
gas delivery. In volume-control mode, delivered volume where QNO is the flow rate of nitric oxide in L/min, CNOset is the
may be larger than, smaller than, or the same as expected desired NO concentration in parts per million (ppm), CNOcyl
depending on the design of the ventilator.14 Only a few ven- is the NO concentration in the cylinder in ppm (usually 800
tilators (Maquet Servo i with heliox option, Hamilton G5 ppm) and the QV is the ventilator gas flow.
with heliox option, and the Viasys Avea with comprehen- The formula is accurate for constant flow systems.
sive model) are designed and calibrated for heliox delivery. This presents a major problem when used with intermit-
Otherwise, the operator needs to be aware of the specific tent breaths (as most modes of ventilation) the patient
ventilator performance and correction formulas and fac- will receive variable amounts of NO (a “bolus” with each
tors14 such that potentially hazardous conditions do not mechanical breath).20 Furthermore, whenever the ventila-
develop. tor settings or the patient breathing pattern changes, the
NO delivery will change. Finally, the use of NO will alter
the gas delivery of the ventilator. For example, the INOvent
NITRIC OXIDE
system will add gas to and extract gas from the deliv-
Inhaled nitric oxide (NO) is used as selective pulmonary ered breath. At 80 ppm it adds 10% more gas, although
vasodilator for patients with pulmonary hypertension, it also withdraws 230 mL/min through the gas-sampling
life-threatening hypoxia, or right-heart failure. Different port. Thus, the oxygen delivered will decrease, and the
devices to deliver NO have been described in the literature. tidal volume may increase. The changes seem to be small
Most of them were custom made and required the use of (unless you see it in pediatric proportions), but it may
mixing chambers, stand-alone NO/nitric dioxide monitors, affect the ventilator’s performance. Furthermore, as a flow
and manual titration of the gas flow. The large amount of of gas is introduced, the flow-triggering performance may
custom-made devices led to inconsistent administration of be affected.
NO.18 In 1998, the American Society for Testing Materials
(ASTM) committee on anesthetic and respiratory equip-
ment developed a standard to provide a minimum degree Trigger Variables
of safety of the devices used to deliver NO. The recom-
mendation was to use a NO administration apparatus, A ventilator-assisted breath can be started (triggered) by
and a NO/nitrogen dioxide analyzer. The Food and Drug the machine or the patient. A machine-triggered breath is
Administration (FDA) enforces this recommendation, and defined by the start of the inspiratory phase independent
 Chapter 3 Basic Principles of Ventilator Design 75

of any signal from the patient. The operator typically sets a TIME
breath frequency for machine-triggered breaths. A patient-
Time is measured by the internal ventilator processor. The
triggered breath is one for which inspiration is started solely
next breath is time triggered (in the absence of a patient
by a signal from the patient. The key operator set variable
trigger event) when the expiratory time has reached the
for patient triggering is sensitivity, or the magnitude of
threshold to maintain a set respiratory rate (e.g., if the set
the patient signal required to initiate inspiratory flow. The
rate is 10 breaths per minute and the inspiratory time is set at
patient signal can be obtained from measuring the airway
1 second, then the expiratory time is 5 seconds). Some modes
pressure, flow, volume, electromyogram (EMG),21 abdomi-
allow the user to set the inspiratory and expiratory time [e.g.,
nal motion (Graseby capsule22), thoracic impedance,23 or any
airway pressure release ventilation (APRV) and biphasic],
other measurable signal of respiratory activity.24 Most inten-
thus fixing the inspiratory-to-expiratory timing (I:E) ratio
sive care ventilators measure pressure and flow (volume is
and respiratory rate. In an effort to improve patient–ventila-
integrated from flow) at the circuit. There are only a few
tor interactions, the ventilator may synchronize the manda-
ventilators that use other sources of signaling, diaphragmatic
tory breath with the patient’s triggering signal if it falls within
EMG (Servo i NAVA), thoracic impedance (Sechrist SAVI),
a threshold. The classic example is synchronized intermit-
and abdominal motion (Infant Star STAR SYNC, which is no
tent mandatory ventilation (SIMV). More recently APRV, as
longer commercially available).24,25
programmed in the Evita XL, delivers a machine breath if
Ventilator triggering characteristics can be evaluated using
the patient trigger signal falls within 25% of the triggering
different metrics.23,26–28 The most sophisticated device for
time.29 Time triggering is also found as a safety mechanism.
evaluating ventilator performance is the ASL lung simulator
The operator or manufacturer enters a time after which the
(IngMar Medical Ltd., Pittsburgh, PA). This device can simu-
apnea alarm will trigger the delivery of a preset breath after a
late both passive lung mechanics (e.g., resistance and compli-
preset time is reached.
ance) as well as patient inspiratory and expiratory effort. It
can display and record pressure, volume, and flow signals, and
PRESSURE
calculate a wide variety of performance metrics. Figure 3-11
shows an example of these waveforms with specific reference The patient inspiratory effort causes a drop in pressure in
points for calculating performance metrics (from opera- the airway and the circuit. Inspiration starts when pres-
tor’s manual for software version 3.2). Using these reference sure falls below the preset “sensitivity” threshold. The site
points we can define the following key trigger metrics: Pmin of measurement will have an impact on the performance
(maximum pressure drop relative to PEEP during the trigger of the device. Pressure signals travel at the speed of sound,
phase), pressure-time product (∫ Paw−PEEP dt from start of approximately 1 ft/ms.30 The farther the sensor is from the
effort to return of airway pressure [Paw] to PEEP), patient signal source, the longer the potential time delay. The closest
trigger work (∫ Paw−PEEP dv from start of effort to return of measurements can be done in the trachea. Tracheal pressure
Paw, to PEEP), and time to trigger (period from the start of measurements reflect actual airway pressure as the endotra-
effort to the return of Paw to PEEP). cheal tube resistance is bypassed. When used for ventilator

80.00
70.00
60.00
Flow
50.00 Volume
40.00
30.00 E F
Paw
20.00 0 B
10.00 4.00
0.00 2.00
–10.00 0.00
–20.00
-Pmus –2.00
D
–30.00 A –4.00 G
–40.00 5.00A
–50.00 0 C
–60.00
Time
0.05 0.1 0 (seconds)
–70.00
0.0116009 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5.0116

FIGURE 3-11 Reference points on pressure, volume, and flow waveforms recorded by the ASL 5000 (IngMar Medical Ltd, Pittsburgh, PA). A. Start
of inspiratory effort, B. beginning of inhalation as determined by the “breath start volume threshold,” C. lowest pressure during the trigger phase,
Pmin, D. return of airway pressure to baseline during the trigger phase, E. end of inspiratory time, i.e., negative-going zero flow crossing, F. begin-
ning of exhalation as determined by the “expiratory start volume threshold,” and G. end of expiratory time, i.e., positive-going zero flow crossing.
(Reproduced, with permission, from Ingmar Medical. ASL 5000 v3.2 Operator’s Manual. Pittsburgh, PA: Author.)
76 Part II Physical Basis of Mechanical Ventilation

TABLE 3-2: ADVANTAGES AND DISADVANTAGES OF THE DIFFERENT CIRCUIT

PRESSURE-SENSING SITES

Advantages Disadvantages

A. Exhalation port: Well protected from mechanical abuse. During Requires protection from moisture of exhaled gas. During spontaneous
mechanical inhalation, accurately reads pressure at the Y. During inspiration, underestimates pressure generated at the Y to trigger the
inhalation, increases in inspiratory or expiratory circuit resistance ventilator. During exhalation, underestimates pressure at the Y. During
do not compromise inspiratory flow output, except for manyfold exhalation, increases in expiratory circuit resistance compromise
increases. expiratory flow. Hence, system requires well-maintained expiratory
filter to ensure that expiratory circuit resistance remains low.
B. Inhalation port: Well protected from mechanical abuse. Does not During mechanical inhalation, overestimates pressure at the Y. During
require protection from moisture or additional filters. During spontaneous inspiration, underestimates pressure generated at the Y
exhalation, accurately reads pressure at the Y as long as the to trigger the ventilator. During inhalation, increases in inspiratory
inspiratory circuit remains patient. During inhalation, increases in circuit resistance compromise inspiratory flow output. For example,
expiratory circuit resistance do not compromise inspiratory-flow factors such as selection of humidifier and type of patient circuit yield
output. varying patient inspiratory efforts for fixed ventilator settings.
C. Patient Y: During inhalation and exhalation, accurately reads both Susceptible to mechanical abuse. Requires a separate pressure-sensing
inspiratory and expiratory pressures. Pressure readings reflect tube, which is prone to occlusion, blockage, and disconnection, all of
relative condition of inspiratory and expiratory circuits. which prevent sensing of patient effort.

Source: Modified, with permission, from Sassoon CSH. Mechanical ventilator design and function: the trigger variable. Respir Care. 1992;37:1056–1069.

triggering, tracheal pressure sensing results in decreased an inspiratory effort, the expiratory flow drops, creating a
work of breathing.31–33 However, tracheal pressure measure- difference between the inspiratory and expiratory flow val-
ments are not routinely done and require special equipment ues. When the difference in values reaches the preset sensi-
(endotracheal tube with monitoring port) and no current tivity threshold, a breath is delivered. Some systems (Puritan
ventilator uses it to routinely trigger the ventilator. Bennett, 7200) allow the operator to set both the bias flow
The other sites of pressure measurement are the patient and the trigger sensitivity. Newer devices set the bias flow
circuit Y or at the inspiratory or expiratory ports, each with according to the operator selected value for the triggering
its advantages and disadvantages (Table 3-2). Trigger perfor- sensitivity. For example, the Puritan Bennett 840 sets the flow
mance will also be affected by the presence of humidifiers, 1.5 L/min above the selected sensitivity, and the Hamilton
filters, water condensation, patient circuit and exhalation G5 automatically sets the bias flow equal to two times the set
valves. These will most often dampen, or rarely amplify, the sensitivity threshold. As a backup, if flow sensor is kinked or
pressure signal. Clinically, the presence of a dampened signal taken out of line, an internal pressure trigger of −2 cm H2O is
will require a larger pressure change (higher work of breath- used until the flow sensor is “online” again.
ing) to reach the trigger threshold. On the contrary, presence Flow change may be detected by placing a sensor just
of water in the pressure tubing may cause oscillation, which before the endotracheal tube. The close proximity to the
can falsely trigger mechanical breaths. patient may enhance triggering. It, however, exposes the sen-
The trigger pressure sensitivity is usually set at 0.5 to sor to secretions and moisture, which may affect its perfor-
1.5 cm H2O below the baseline pressure. Common practice mance. Flow triggering seems more efficient than pressure
is to increase the sensitivity (i.e., decrease the pressure drop) triggering in terms of work of breathing.34 This, however,
until autotriggering occurs and then reduce sensitivity until seems of no particular clinical relevance in the presence of
the autotriggering just stops.30 Note that each ventilator appropriately set pressure triggering.35 Flow sensing may
comes with predetermined manufacturer set values and can cause autotriggering secondary to noninspiratory flow
be adjusted. changes. The flow change can happen in either the ventilator
circuit (leak in the circuit or endotracheal tube) or the patient
(cardiogenic oscillations or bronchopleural fistula).36,37
FLOW
A novel approach to flow triggering is offered on the
Flow triggering is based on the detection of a change in a Dräger Infinity V500 ventilator in the APRV mode. Rather
constant, small, baseline (bias) flow through the patient cir- than setting a T-low time to determine the time triggering
cuit. The operator sets a flow sensitivity threshold. When the of each mandatory breath, the operator may set a percent of
change in flow reaches the threshold, a breath is delivered. peak expiratory flow as the trigger threshold.
The changes in flow are detected at the expiratory valves or
by a flow sensor in the patient circuit. The ventilator mea- VOLUME
sures the flow from the ventilator and from the patient. In
a closed circuit, the two flow values should remain equal A breath may be triggered when a preset volume is detected
in the absence of patient effort. When the patient makes as the result of a patient inspiratory effort. This is similar to
 Chapter 3 Basic Principles of Ventilator Design 77

flow triggering but using volume has the theoretical advan- adjusted. The cardiac cycle may also cause interference with
tage of being less susceptible to signal noise (i.e., integrat- the signal.22,25
ing flow to get volume cancels out some noise because of
flow oscillations). Volume triggering is rare in ventilators
but can be found on the Dräger Babylog VN500 infant Target Variables
ventilator.
During inspiration, the variable limiting the magnitude
of any parameter is called the target variable (previously
DIAPHRAGMATIC SIGNAL known as the limit of the control variable, but the term
limit is now reserved for alarm and safety conditions rather
The ideal approach to coordinate a mechanical ventilator
than control settings).42A target is a predetermined goal of
with the patient inspiratory effort would be to use the neu-
ventilator output. Targets can be viewed as the parameters
ral output of the respiratory center. Direct measurement of
of the targeting scheme (see Chapter 2). Within-breath tar-
the respiratory center output is currently not possible. The
gets are the parameters of the pressure, volume, or flow
phrenic nerve has been used as a trigger signal in animal
waveform. Examples of within-breath targets include
models,38,39 but not in humans. The only available clinical
inspiratory flow or pressure rise time (set-point targeting),
approach is measurement of the diaphragmatic electrical
inspiratory pressure and tidal volume (dual targeting), and
activity (Edi). Because the Edi is an electric signal, it easily
constant of proportionality between inspiratory pressure
becomes contaminated by the electrical activity of the heart,
and patient effort (servo targeting). Between-breath targets
the esophagus, and other muscles.21 More importantly, the
serve to modify the within-breath targets and/or the over-
Edi requires an intact respiratory center, phrenic nerve,
all ventilatory pattern. Between-breath targets are used with
neuromuscular junction, and assumes that the diaphragm is
more advanced targeting schemes, where targets act over
the primary inspiratory muscle (e.g., rather than accessory
multiple breaths. A simple example of a between-breath
muscles of ventilation).
target is to compare actual exhaled volume to a preset
The only clinically available system that uses diaphrag-
between-breath tidal volume so as to automatically adjust
matic signal trigging is the neurally adjusted ventila-
the within-breath constant pressure or flow target for the
tory assistance (NAVA) system. An esophageal catheter is
next breath. Examples of between-breath targets and tar-
used to measure the Edi. The sensitivity is set by entering
geting schemes include average tidal volume (for adap-
a value above the background electrical noise. The trigger
tive targeting), percent minute ventilation (for optimal
value is set in microvolts and represents the change in the
targeting), and combined partial pressure of carbon dioxide,
electrical signal rather than an absolute value.40 The default
volume, and frequency values describing a “zone of comfort”
setting is 0.5 microvolts, but it can be adjusted from 0 to
(for intelligent targeting).
2 microvolts. As a backup trigger signal in the absence of
a measurable Edi, NAVA uses flow or pressure triggering,
whichever happens first. PRESSURE
The ventilator uses microprocessors to control the delivery
of pressure. The pressure can be delivered with any pres-
OTHER SIGNALS
sure profile and in response to many signals. Currently,
The BiPAP Vision (Respironics Inc., Murrysville, PA) uses most modes of ventilation in which inspiratory pressure is
a triggering mechanism called shape-signal. The ventila- targeted deliver the pressure rapidly and attempt to main-
tor microprocessor generates a new flow signal, which tain the pressure constant throughout the inspiratory phase
is offset from the actual flow by 0.25 L/s and delays it for (square waveform). This means that the performance of the
300 milli seconds. The delay causes the flow shape signal ventilator depends on the delivery of the pressure wave-
to be slightly behind the patient’s flow rate. The mechani- form and any departure from the ideal waveform leads to
cal breath is triggered when a sudden decrease in expiratory differences in performance between ventilators.43,44
flow from an inspiratory effort crosses the shape signal.41
The Sechrist SAVI system (Sechrist Industries, Anaheim, Inspiratory Pressure. The pressure rise during inspiration
CA) is the only mode available that uses transthoracic associated with volume and flow delivery is set by
electrical impedance to trigger the ventilator.25 The tho- the operator (pressure control–continuous mandatory
racic impedance is obtained by placing two chest leads, ventilation) or closed-loop algorithms (e.g., pressure-
one in the anterior axillary line on the right and the other regulated volume control). Care should be exercised while
in the posterior axillary line on the left. The sensors are setting the ventilator or reading the literature as there is
placed high enough to avoid costal and subcostal retrac- significant variability between ventilator manufacturers and
tions. The chest sensors measure the electrical impedance peer-reviewed literature in the definitions and nomenclature
across the human body. As a breath occurs, the transtho- related to inspiratory pressures.43 The main problem
racic impedance changes as a result of a different ratio of stems from what historically has been used to define the
air-to-fluid in the thorax. The triggering threshold can be inspiratory pressure. For example, in the same ventilator, for
78 Part II Physical Basis of Mechanical Ventilation

Spontaneous breath

Pressure support (above P-high)

Pressure
support
Inspiratory pressure Pressure
Inspiratory pressure support
Pressure
support

PEEP
CPAP
P-low

Mandatory breath Spontaneous breath

FIGURE 3-12 Idealized airway pressure waveform showing various conventions used for pressure parameters. Note that there are two ways
to define inspiratory pressure for mandatory breaths (green) and four ways to define inspiratory pressure (i.e., pressure support) for spontane-
ous breaths (red). CPAP, continuous positive airway pressure; PEEP, positive end-expiratory pressure; P-high, high pressure; P-low, low pressure.
(Reproduced, with permission, from Chatburn RL, Volsko TA. Documentation issues for mechanical ventilation in pressure-control modes. Respir
Care. 2010;55(12):1705–1716.)

pressure control–continuous mandatory ventilation breaths and peak airway pressure are synonymous. For example,
the peak inspiratory pressure is stated in reference to the measured peak airway pressure is often higher than set peak
set end-expiratory pressure (PEEP), but for APRV the peak inspiratory pressure because of pressure transients from an
inspiratory pressure is stated in reference to the atmospheric underdamped pressure-control system or noise from patient
pressure. To compound the confusion, on some ventilators movement. The introduction of the so-called active exhala-
the value of pressure support is set relative to PEEP (e.g., tion valve made possible unrestricted spontaneous breaths
Drager Evita XL, Puritan Bennett 840), on others (LTV 950) during the inspiratory phase of a mandatory pressure-
pressure support is set relative to the atmospheric pressure control breath. New modes brought new terms. For
(i.e., atmospheric pressure = zero airway pressure), and on at example, P-high or PEEP high refers to the peak inspiratory
least one ventilator (BiVent in Servo i) pressure support may pressure above atmospheric pressure in APRV (again, there
be set relative to inspiratory pressure (P-high). Figure 3-12 is no standardization of either terminology or symbology
illustrates the two different ways used to define inspiratory in this mode).
pressure and the four different ways to define pressure
support. Figure 3-13 illustrates the proposed solution to this Pmax. The Drager Evita XL, when set in volume-control
problem.43 In this proposal, the term inspiratory pressure modes, allows the operator to set the maximum pressure
is defined as the set change in airway pressure during (Pmax) that can be achieved during the delivery of a
inspiration relative to set end-expiratory airway pressure mandatory breath. The goal is to prevent pressure peaks
during pressure-control modes. while maintaining the set tidal volume. When the Pmax is
On some ventilators, inspiratory pressure rise is set rela- reached during a given inspiration, the ventilator switches
tive to atmospheric pressure rather than set end-expiratory from volume control to pressure control (dual targeting)
pressure. To distinguish this from inspiratory pressure as using the Pmax setting as the inspiratory pressure target. If
defined relative to PEEP, the term peak inspiratory pressure the set tidal volume cannot be reached in the set inspiratory
has been proposed.43 In contrast “peak airway pressure” is time, the ventilator will alarm.45
the measured peak airway pressure relative to atmospheric
pressure. Often, for a good pressure-control system, there Rise Time. The speed with which the airway pressure
is seemingly no difference between set peak inspiratory reaches the set inspiratory pressure is called the rise time.
pressure and measured peak airway pressure on the airway- (Rise time for flow can be set in the Maquet Servo i, but
pressure waveform during pressure-control modes. And this feature is rare on ventilators.) The rise time may be
even if the operator sees a transient small difference, this is set by the operator or automatically adjusted based on a
not considered clinically important in most nonalarm cases. computer algorithm (e500, Newport Medical Instruments
This leads clinicians to conceptually oversimplify what they Inc, Newport Beach, California). The name used to indicate
see and make the mistake of assuming inspiratory pressure pressure rise time varies by ventilator brand (e.g., inspiratory
 Chapter 3 Basic Principles of Ventilator Design 79

Spontaneous breath

PS-PIP
Airway pressure

Airway pressure
IP PS-PEEP Pplt PS-PEEP
PIP PS-Patm Ppeak PS-Patm

PEEP PEEP

Mandatory breath Spontaneous breath Mandatory breath Spontaneous breath

Spontaneous
Volume

Mandatory Spontaneous Volume Mandatory Spontaneous

Mandatory
Mandatory
Spontaneous
Flow

Flow

Spontaneous Spontaneous Spontaneous

expiration Mandatory Mandatory expiration
expiration
expiration expiration

FIGURE 3-13 Idealized pressure, volume, and flow waveforms for pressure control and volume control illustrating the use of proposed conventions
for both set and measured airway pressures. IP, inspiratory pressure; PEEP, positive end-expiratory pressure; PIP, peak inspiratory pressure; Ppeak,
peak pressure; Pplt, plateau pressure; PS-Patm, pressure support relative to atmospheric pressure; PS-PEEP, pressure support relative to positive end
expiratory pressure; PS-PIP, pressure support relative to peak inspiratory pressure. (Reproduced, with permission, from Chatburn RL, Volsko TA.
Documentation issues for mechanical ventilation in pressure-control modes. Respir Care. 2010;55(12):1705–1716.)

slope, P-ramp, plateau%, and slope rise time). Adjusting slow rise time should be avoided. A more gradual rise may be
the rise time influences the synchronization between the needed in awake patients (for comfort) or patients with low
patient and the ventilator secondary to changes in the initial compliance to prevent pressure overshoot and premature
inspiratory flow rate. The lower the rise time, the faster the cycling of inspiration (Fig. 3-14).
pressurization rate46 and the higher the peak inspiratory
flow.47 A higher initial inspiratory flow rate may decrease
TIDAL VOLUME
the work of breathing but can lead to patient discomfort and
worse patient–ventilator synchrony. Conversely, too slow The operator is required to enter a tidal volume in any
a rise time may result in increased work of breathing and volume-control mode. This may be a direct setting or an indi-
longer mechanical inspiratory time, leading to a dissociation rect one by setting frequency or minute ventilation. The ven-
between patient breathing effort and the mechanical breath. tilator will control the tidal volume and the pressure will be
That is, the relation between work of breathing, respiratory the dependent variable. A tidal volume target, however, may
drive, and comfort with the duration of the rise time is not also be set when the mode uses adaptive targeting in pressure
proportional.46,48 Because rules for setting an optimal rise control (e.g., pressure-regulated volume control [PRVC] on
time are lacking, based on these studies, both very rapid and the Maquet ventilators).49 In such a case, inspiratory pressure
80 Part II Physical Basis of Mechanical Ventilation

A B C
2
1
(L/S)
Flow

0
–1
–2

2.0
1.5
1.0
Volume
(L)

0.5

–0.5

60

40
(cm H2O)
pressure
Airway

20

–20

60
Esophageal

40
(cm H2O)
pressure

20

–20
FIGURE 3-14 Examples of different pressure rise times in three breaths in pressure-support mode. A. Rise time is set very low, resulting in a lower
peak inspiratory flow. B. Rise time is set higher, resulting in a higher peak flow and shorter inspiratory time. C. Rise time is set very high, resulting
in “ringing” of airway pressure signal and peak flow that is uncomfortable to the patient, who exerts an expiratory effort and prematurely terminates
inspiration (indicated by the positive deflection of esophageal pressure). (Reproduced, with permission, from Macintyre NR. Patient-ventilator inter-
actions: optimizing conventional modes. Respir Care. 2011;56(1):73–81.)

is automatically adjusted between breaths by the ventilator to mode, when, by the equation of motion, what is being
achieve an average measured tidal volume equal to the oper- controlled is pressure during a breath. A caveat with this
ator set target. There are four basic ways ventilators deliver targeting scheme is that in the presence of the patient’s
a preset tidal volume (from least used to most commonly inspiratory efforts, the tidal volume may be higher than
used): set, and the support provided by the ventilator may be
inappropriately low.50,51
1. By measuring the volume delivered and using the signal
4. By controlling flow, the volume delivered is indirectly
in a feedback control loop to manipulate the volume
controlled. Because flow and volume are inverse functions
waveform.
of time (i.e., volume is the integral of flow and flow is the
2. By the displacement of a piston or bellows. An example
derivative of volume), controlling one controls the other.
of this is the Puritan Bennett LP10 home-care ventilator
In simple ventilators, there is no feedback signal for flow,
(piston) or some anesthesia ventilators (bellows).
just a known flow for an adjustable amount of inspira-
3. By controlling the inspiratory pressure within a breath
tory time. On more sophisticated ventilators, the operator
and automatically adjusting it between breaths to deliver
can regulate the shape of the inspiratory flow waveform.
a minimum set tidal volume. The volume delivered is
A square waveform will create higher peak airway pres-
targeted by a closed-loop algorithm, known as adaptive
sures and will require less time to deliver the set volume
pressure control (see Chapter 2). This targeting scheme
(which may result in lower mean airway pressures) than
is available in most modern critical care ventilators under
a descending ramp pattern.52–54 Some ventilators offer
multiple names (e.g., PRVC, autoFlow, VC+, APV).
one waveform (e.g., the Dräger Evita XL offers only the
A common confusion is that this is a volume-control
 Chapter 3 Basic Principles of Ventilator Design 81

VC (Set-point targeting) Tidal volume

set by operator
Volume

Flow Patient
PC (Adaptive targeting) Target tidal volume
set by operator
Volume
Airway Pressure
pressure

PC (Set-point targeting) Inspiratory pressure

set by operator
Airway
pressure

No respiratory Small respiratory Larger respiratory

effort effort effort
FIGURE 3-15 Volume delivery in volume control (VC) and pressure control (PC) modes using set-point targeting versus pressure control using adap-
tive targeting. Notice how tidal volume (flow) remains constant in volume control with set-point targeting in the setting of increased patient effort. In
adaptive pressure targeting, the inspiratory pressure is adjusted by an algorithm to keep the tidal volume at a target. The tidal volume, however, may
be larger if the patient effort is large enough. In set-point pressure targeting, the pressure remains constant, and the tidal volume increases in response
to patient effort.

square waveform) others have more (e.g., the Hamilton tidal volume and frequency. The ventilator then monitors
Veolar offers 50% or 100% descending ramps, sinusoidal, the total minute ventilation as the sum of the minute ven-
and square).55 Most current ventilators only provide the tilations generated by mandatory and spontaneous breaths.
square waveform or a descending ramp profile. If the total minute ventilation is below the target value, the
mandatory breath frequency will increase. As long, however,
Figure 3-15 compares volume delivery between standard
as the spontaneous minute ventilation is at least equal to the
volume and pressure control modes versus modes using
target value, mandatory breaths will be suppressed. In this
adaptive pressure control.
way, the proportion of the total minute ventilation gener-
ated by spontaneous breaths can range from 0% to 100%.
As a result, MMV may be considered a mode of automatic
MINUTE VENTILATION
weaning.
In volume-control modes, the minimum minute ventilation Another version of MMV was used on the Hamilton
is set by entering the tidal volume and respiratory rate. This Veolar ventilator (now obsolete); the target minute venti-
assures that the patient will receive a minimum amount of lation was maintained by automatic adjustment of inspira-
ventilatory support. Some modes provide the option to enter tory pressure (adaptive pressure support). That mode was
a target minute ventilation (as a percent of the calculated replaced by ASV on newer Hamilton ventilators.49 ASV is the
minute ventilation for a given ideal body weight, adaptive- only commercially available mode to date that uses optimal
support ventilation [ASV]; e.g., Hamilton G5), while others targeting. It was first described by Tehrani in 1991.57 The
will calculate it from the entered tidal volume and respira- operator inputs the patient’s height and percent of minute
tory rate (mandatory minute volume [MMV]; e.g., Dräger ventilation to be supported (25% to 350%). The ventila-
Evita XL). The concept of automatically adjusting the venti- tor then calculates the ideal body weight and estimates the
lator settings to maintain a constant minute volume was first required minute alveolar ventilation assuming a normal
described by Hewlett and Plat in 1977.56 As implemented, dead space fraction. Next, an optimum frequency is calcu-
for example, on the Dräger Evita XL ventilator, MMV is a lated based on work by Otis et al9 that predicts a frequency
form of volume control–intermittent mandatory ventilation. resulting in the least mechanical work rate. The target
The operator presets the target minute ventilation by setting tidal volume is calculated as minute ventilation divided by
82 Part II Physical Basis of Mechanical Ventilation

TABLE 3-3: DETERMINANTS OF MINIMUM AND MAXIMUM MINUTE VENTILATION FOR

SOME COMMON MODES
Mode Name A/C SIMV MMV ASV Smart Care

Operation Operator enters a Operator enters Operator enters a set Adaptive pressure Pressure support
set rate and tidal a set rate and rate and tidal volume. control breaths is titrated based
volume. Patient tidal volume. Patient may breath with target tidal volume on expert rules to
may trigger breaths Patient may or without assistance. If and rate according achieve the range
above set rate. breath in between his minute ventilation to mathematical etPCO2.
mandatory breaths falls below minimum, model.
with or without then mandatory breaths
assistance. initiate at a set rate.
Control variable Volume Volume Volume Pressure Pressure
Breath sequence CMV IMV IMV IMV CSV
Minimum minute set VT × set f set VT × set f set VT × set f Targeted by ventilator Targeted by ventilator
ventilation based on operator- to maintain
entered body “comfort zone”
weight. based on VT, f, and
etPCO2.
Maximum Variable: VT × total f Variable: VT × total f Variable: VT × total f Variable but ventilator Variable but ventilator
minute will reduce support will reduce support
ventilation if patient attempts if patient attempts
to increase above to increase above
estimated minute estimated minute
ventilation ventilation
requirement. requirement.

Abbreviations: A/C, assist/control; ASV, adaptive support ventilation; etPCO2, end-tidal pressure of carbon dioxide; f, ventilatory frequency—total f reflects the sum of
machine- and patient-triggered breaths; MMV, mandatory minute volume; SIMV, synchronized intermittent mandatory ventilation; VT, tidal volume.

respiratory frequency (MV/f). In ASV, there are two breath mode.27 Second, the interface may add confusion. For exam-
patterns based on the patient’s respiratory effort. If there is ple, in the Dräger Evita XL, while on volume control, the
no patient effort, the ventilator delivers adaptive pressure- operator will need to set the inspiratory flow, the inspiratory
control ventilation; if there is patient effort, the patient time, and tidal volume, whereas on the Hamilton G5, the
receives adaptive pressure support. In both instances, the options are customizable in three different ways! (Hopefully,
inspiratory pressure within a breath is controlled to achieve all conducive to the same output.) The operator can enter
a target tidal volume.49 (a) the I:E and the percent pause in inspiration, (b) the peak
Table 3-3 summarizes the determinants of minimum and inspiratory flow and inspiratory time, or (c) the percent
maximum minute ventilation for some common modes. inspiratory time and plateau pause time. Underscoring that
knowledge of the device used is essential. Finally, to add to
the confusion, there are incorrect conclusions that some-
INSPIRATORY FLOW times permeate practice:
The inspiratory flow can be adjusted by the operator on 1. In pressure-control mode, the flow is controlled as a
most ventilators that provide volume-control modes (see descending ramp. In a pressure-controlled breath, the vol-
“Tidal Volume” above). In general, the ventilator operator ume and the flow are the manifestation of the respiratory
will choose a peak flow and may have some waveform pat- system characteristics (resistance and compliance) and
tern options (e.g., square waveform or descending ramp). the patient’s respiratory effort. If the patient is passive (no
Although these settings appear simple, there are several respiratory effort), the flow will decay exponentially (see
points that may cause differences in performance and inter- Fig. 3-7, A). If the patient has a respiratory effort, the flow
pretation of data. First, the ventilator uses a microprocessor pattern will be variable, according to the characteristics of
to control the delivery according to the preset tidal volume, the patient effort, the ventilator settings (inspiratory pres-
inspiratory time, flow pattern, pressure limits, and ventila- sure, pressurization algorithm, triggering, etc.), and the
tor-specific algorithms. During the breath, the flow delivery respiratory system characteristic. The only way to have a
is adjusted according to a closed-loop feedback mechanism standard descending ramp is to select that waveform and
and proprietary software.2 The consequence is a difference have the computer control the flow delivery in volume
in performance among ventilator brands, even in the same control.
 Chapter 3 Basic Principles of Ventilator Design 83

2. The “autoflow” function adjusts the flow in a volume- In 1996, Davis et al52 tested the hypothesis that a descend-
controlled breath to the patient’s demand. Autoflow is ing ramp flow waveform is responsible for improvements in
available in Dräger Evita ventilators. It appears as an gas exchange during pressure-control ventilation for acute
add-on for three modes of volume-control ventilation lung injury. They compared volume control with a square or
(controlled mechanical ventilation [CMV] or intermittent descending ramp waveform to pressure control with a square
positive-pressure ventilation [IPPV], SIMV, and MMV). pressure waveform. Both pressure control and volume con-
This “add on” is defined in the manual as automatic trol with a ramp waveform provided better oxygenation at
regulation of the inspiratory flow adjusted to the changes lower peak airway pressure and higher mean airway pres-
in lung conditions and to the spontaneous breathing sure compared to volume control with the square-flow
demands.58,59 What this “add on” does is turn the mode waveform.
from a volume-control mode to an adaptive pressure- Polese et al61 compared square, sinusoidal, and descend-
control mode. This is the same as being on PRVC on ing ramp flow waveforms in patients after open heart
the Maquet ventilators. They all automatically adjust the surgery. They found that PaO 2 and PaCO 2 were not affected
inspiratory pressure to achieve a target tidal volume and by changes in waveform. Peak airway pressure was high-
because this is a pressure-controlled breath, the flow will est with the sinusoidal waveform while mean airway pres-
be variable (see “Tidal Volume” above). sure and total work of breathing were least with the square
waveform. Yang et al53 applied square, sine, and descending
The inspiratory flow setting has importance at differ-
ramp flow waveforms to patients with chronic obstructive
ent levels. The work of breathing is related to the peak flow
pulmonary disease (COPD) and found that the descend-
and the pressurization rate. The balance between patient
ing ramp reduced inspiratory pressure, dead space-to-tidal
and ventilator work of breathing will be affected by the
volume ratio, and PaCO 2, but increased alveolar–arterial
inspiratory flow setting. In regards to cycling, high flows
oxygen tension difference with no change in arterial oxygen-
can lead to high peak inspiratory pressures (peak inspira-
ation or hemodynamic variables.
tory pressure [PIP] is directly proportional to resistance,
Our own experience is that many clinicians prefer the
the higher the flow, the higher the PIP), which may lead to
descending ramp flow waveform when using volume control
reaching the pressure or flow-cycling threshold and ending
modes, with the observation that patients tend to be more
the breath prematurely.59 But a more practical issue is this:
comfortable, perhaps because of the higher flow earlier in
does the flow-wave shape itself have any effect on patient
the inspiratory phase.
outcome? Like most other questions about ventilator set-
Figure 3-16 illustrates an algorithm that can be used
tings affecting patient outcome, after more than 30 years
to adjust inspiratory flow to improve patient–ventilator
of research on this particular subject we still do not know
synchrony.62
the answer.
Studies from the early 1960s to early 1980s produced
conflicting results, prompting Al-Saady and Bennett to PERCENT SUPPORT
design a better-controlled study, keeping tidal volume,
minute ventilation, and I:E ratio constant.60 They dis- Proportional-assist ventilation (PAV)63 delivers pressure-
covered that compared to a constant inspiratory flow, a control breaths with a servo targeting scheme (see Chapter
descending ramp flow (what they and many subsequent 2).49 The pressure applied is a function of patient effort: the
authors have called “decelerating flow”) resulted in a lower greater the inspiratory effort, the greater is the increase in
peak airway pressure, total respiratory resistance, work of applied pressure (Fig. 3-17). The form of PAV implemented
inspiration, dead space-to-tidal volume ratio, and alveo- on the Dräger Evita XL ventilator (called proportional pres-
lar–arterial oxygen tension gradient. They also noted an sure support) requires the operator to input desired assis-
increase in compliance and partial pressure of arterial oxy- tance values for elastance and resistance. PAV implemented
gen (PaO 2) with no changes in partial pressure of arterial on the Puritan Bennett 840 ventilator (called PAV +) uses a
carbon dioxide (PaCO 2) or any hemodynamic variables. In different algorithm. It automatically calculates the resistance
1991, Rau et al compared peak and mean airway pressure of the artificial airway, and combines resistance and elas-
for seven different inspiratory flow waveforms (including tance such that the operator enters only a single value repre-
square, ascending and descending ramps, and sinusoidal) senting the percentage work of breathing to be supported.64
under three different lung model conditions.54 For all mod- The design differences between proportional pressure sup-
els, the descending ramp flow waveform produced the low- port and PAV + lead to significant performance differences.65
est peak and the highest mean airway pressures, whereas
the ascending ramp produced the opposite: the highest
NEURALLY ADJUSTED
peak and lowest mean values. When compliance was low,
VENTILATORY SUPPORT LEVEL
mean airway pressure increased as peak airway pressure
increased. When resistance was high, peak airway pres- NAVA is a mode that applies airway pressure proportion-
sure was more affected by the peak flow setting than the ately to patient effort based on the voltage recorded from
waveform setting. diaphragmatic activity. The “NAVA level” is the constant
84 Part II Physical Basis of Mechanical Ventilation

Identify candidate
patient

Assess patient

Add PEEP
5 cm H2O or
increase by PEEPi > 5 Add PEEP
No Yes
1 cm H2O not cm H2O 75–80% of PEEPi
to exceed
8 cm H2O

No Al > 10%

Yes

Set tidal volume

6–8 mL/kg

Increase Pressure
No
inspiratory flow control mode

Yes

Increase
pressurization rate

Decrease
Yes Time cycled
inspiratory time

No

Increase flow- Long time

cycle threshold Yes constant
(% peak flow) (COPD)

No

Decrease flow
cycle threshold
(% peak flow)

FIGURE 3-16 Algorithm for improving patient–ventilator synchrony. AI, asynchrony index, percent of inspiratory efforts that failed to trigger a
breath; COPD, chronic obstructive pulmonary disease; PEEPi, intrinsic PEEP (aka auto-PEEP). (Modified from, with permission, Sassoon CSH.
Triggering of the ventilator in patient-ventilator interactions. Respir Care. 2011;56(1):39–48.)
 Chapter 3 Basic Principles of Ventilator Design 85

Proportional-assist ventilation

Volume Pressure

Patient
Flow, pressure, and volume delivered
Ventilator measuring effort Flow by the ventilator are adjusted
respiratory system proportionally to patient effort
characteristics
FIGURE 3-17 Pressure, volume, and flow waveforms for proportional assist ventilation.

of proportionality (gain) between voltage and airway pres- Cycle Variables

sure. The operator enters the NAVA level, then the ven-
tilator delivers pressure equal to the product of gain and The inspiratory phase of a mechanical breath ends (cycles
the Edi. In simple terms, it states how much pressure the off) when a threshold value for a measured variable is
patient will receive for each microvolt of diaphragmatic reached. This variable is called the cycle variable, and it ends
activity: the inspiratory time. Cycling is characterized by the initiation
Paw(t) = Edi(t) × NAVA level (8) of expiratory flow. The cycle variable may be preset (by the
operator or the ventilator manufacturer), or automatically
where Paw(t) is the airway pressure (cm H2O) as a function defined by the ventilator. Many different signals are used, for
of time (t), Edi(t) is the electrical activity of the diaphragm example, time, volume, pressure, flow, diaphragmatic signal,
as a function of time (t), in microvolts (µV), and the NAVA and thoracic impedance.
level is the operator-set level of support in cm H2O/µV. The
range is 0 to 30 cm H2O/μV.
INSPIRATORY TIME
The NAVA level is set according to the operator ventila-
tion goals, level of inspiratory pressure support, tidal vol- Inspiratory time is defined as the period from the start of
ume, apparent patient work of breathing, or respiratory rate. inspiratory flow to the start of expiratory flow. Inspiratory
Recently, Roze et al66 proposed using the maximum Edi dur- time has two components; inspiratory flow time (period
ing a spontaneous breathing trial to help set the NAVA level when inspiratory flow is above zero) and inspiratory pause
(Fig. 3-18). By titrating the NAVA level to the a target Edi, the time (period when flow is zero). In pressure-controlled or
goal is to avoid excessive diaphragmatic unloading as well as volume-controlled breaths, the inspiration is cycled (termi-
respiratory muscle fatigue. nated) when the set inspiratory time elapses. In spontane-
ous modes of ventilation (NAVA, PAV, pressure support), the
inspiratory time is dependent on the patient’s own neurally
AUTOMATIC TUBE COMPENSATION determined inspiratory time, level of support, cycling rule
Automatic tube compensation (ATC) is a mode that com- (flow, pressure, time, diaphragm activity), and safety rules
pensates for the flow-dependent pressure drop across an (maximum set inspiratory time).
endotracheal tube during inspiration and expiration. It is Inspiratory time is usually an operator-entered input
thus intended to reduce or eliminate the resistive work of but some modes of ventilation can automatically set it and
breathing imposed by the artificial airway. ATC is an add- change it based on expert rules and closed-loop feedback
on feature on several ventilators. When ATC is activated, algorithms. Two notable algorithms are ASV and Adaptive
the ventilator supplies airway pressure in proportion to I-Time. In ASV (Hamilton G5), the inspiratory time is auto-
the square of flow times, a gain factor that is determined matically set at one expiratory time constant (of the measured
by the size of the endotracheal tube. Because flow is posi- respiratory system characteristics and it is never shorter than
tive during inspiration and negative during expiration, 0.5 second or longer than 2 seconds). In the Adaptive Flow
ATC pressure either adds to inspiratory pressure or sub- and Adaptive I-Time in the Versamed iVent (GE Healthcare,
tracts from expiratory pressure (Fig. 3-19). Some ven- Madison, WI), the ventilator automatically adjusts the inspi-
tilators calculate and display tracheal pressure as airway ratory time and inspiratory flow to maintain a target I:E ratio
pressure minus ATC pressure. ATC can be used alone of 1:2 and deliver the operator-set tidal volume.49
or added to the ventilating pressure in pressure-control In volume-control modes, there are four possibilities for
modes. Interestingly, the way ATC was implemented in the setting inspiratory time:
intensive care unit ventilators is different from the original 1. Operator sets tidal volume and inspiratory flow: inspira-
concept, where negative pressure could be applied during tory time is equal to the tidal volume divided by mean
exhalation.67,68 inspiratory flow.
86 Part II Physical Basis of Mechanical Ventilation

Paw Paw
[cm H2O] [cm H2O]

PEEP PEEP

Tiex Time [s] Time [s]

Tiv Tiv Tiex

Flow Flow
[L/sec] [L/sec]

Time [s]
Time [s]

Edi Edi
[µv] [µv]

Tin Time [s] Tin Time [s]

Td

FIGURE 3-18 Airway pressure, flow, and electrical diaphragmatic activity curves in pressure support (left) and in neurally adjusted ventilatory assist
(right). Edi, electrical activity of the diaphragm; PEEP, positive end-expiratory pressure, Td, trigger delay; Tiex, inspiratory time in excess; Tin, neural
inspiratory time; Tiv, ventilator pressurization time. (Reproduced, with permission, from Piquilloud L, Vignaux L, Bialais E, et al. Neurally adjusted
ventilatory assist improves patient–ventilator interaction. Intensive Care Med. 2011;37(2):263–271.)

Extra inspiratory assist due to ATC

2. Operator sets tidal volume and inspiratory time: mean
inspiratory flow is equal to the tidal volume divided by
Set inspiratory pressure the inspiratory time.
Pressure

3. Operator sets tidal volume, inspiratory flow, and inspira-

tory time: if the inspiratory time is longer than the inspi-
ratory flow time (set tidal volume divided by set flow),
Estimated tracheal pressure then an inspiratory hold is created and the pause time is
equal to the inspiratory time minus the inspiratory flow
time. For example, if the tidal volume is 600 mL (0.6 L)
Time and the set inspiratory flow is 60 L/min (1L/s) then the
inspiratory flow time is (0.6/1 = 0.6 s). Now, if the opera-
Expiratory assist due to ATC tor also sets the inspiratory time to 1 s, an inspiratory
FIGURE 3-19 Pressure waveforms illustrating automatic tube com- pause is created and it lasts 1.0 − 0.6 = 0.4 s.
pensation (ATC). (Modified, with permission, from Dräger Medical 4. On some ventilators, the operator sets pause time
AG & Co. KG. Infinity V500 Operator’s Manual. Luebeck, Germany.) directly.
 Chapter 3 Basic Principles of Ventilator Design 87

In pressure-control modes, the operator presets the inspi- effect on oxygenation and ventilation by increasing mixing
ratory time directly for mandatory breaths. Thus, prolong- time and decreasing dead space.69,70
ing the inspiratory time causes the ventilator to decrease
the expiratory time, possibly resulting in air trapping, larger I:E Ratio and Duty Cycle. I:E is the ratio of inspiratory time
tidal volumes, or cycle asynchrony. One must remember to expiratory time (Fig. 3-20).
that the effect on tidal volume of the inspiratory time in a
TI
pressure-control breath will depend on the respiratory sys- I : E = TI : TE = (9)
tem characteristics (i.e., the time constant). Thus, a patient TE
with a long time constant (high compliance and/or high
The I:E can also be described as the duty cycle or percent
resistance) will require a longer inspiratory time to achieve
inspiration. In engineering, the duty cycle is defined as the
full pressure equilibration, cessation of flow, and complete
time spent in active state as a fraction of the total time. In
tidal volume delivery.
mechanical ventilation, the active state is the inspiratory
Figure 3-16 illustrates an algorithm that can be used
time, and the total time is the sum of the inspiratory and
to adjust inspiratory time to improve patient–ventilator
expiratory times. It is expressed as a percentage. The larger
synchrony.62
the percentage, the longer the inspiratory time in relation to
the total cycle time.
Inspiratory Pause. The inspiratory pause is the period
during which flow ceases but expiration has not begun TI
Duty Cycle = × 100 (10)
(see inspiratory time). The expiratory valves are closed TI + TE
during this period. The inspiratory pause time is part of
the inspiratory time. It is also named plateau time (PB 840, One can convert one to the other by the following formula:
Covidien, Mansfield MA), Pause time (Servo i, Maquet,) Duty Cycle
or Pause (G5, Hamilton Medical). When set directly, pause I:E = (11)
100 − Duty Cycle
time may be entered in seconds or as a percentage of the
inspiratory time. When it is activated, most ventilators Example: A duty cycle of 50% is an I:E of 1:1, a duty cycle of
will display a plateau pressure (i.e., static inspiratory hold 33% is an I:E 1:2.
pressure). Increasing the inspiratory pause time will increase The relevance of I:E is highlighted in the context of
the mean airway pressure and thus the time the lung is the time constant. The time constant is a measure of how
exposed to volume and pressure. This may have a positive quickly the respiratory system can passively fill or empty in

A
B C

IT Expiratory time

IFT IPT Expiratory time

IT Expiratory flow time Expiratory pause time

Inspiration Expiration

Total cycle time

FIGURE 3-20 Divisions of the inspiratory and expiratory periods. A volume-controlled breath is depicted. A. End of inspiratory flow. B. Start of
expiratory flow. C. End of expiratory flow. IFT, Inspiratory flow time; IPT, inspiratory pause time; IT, inspiratory time.
88 Part II Physical Basis of Mechanical Ventilation

TABLE 3-4: EFFECT OF LUNG CONDITION ON TIME CONSTANT AND EXPIRED VOLUME

Expiratory Time (s) Expiration

Tidal Volume Tidal Volume Tidal Volume

Time Constant Normal Lung ARDS COPD Remaining (mL) Exhaled Remaining

0 0 0 0 500 0 100
1 0.780 0.510 1.000 184 63%a 37%
2 1.560 1.020 2.000 68 86% 14%
3 2.340 1.530 3.000 25 95% 5%
4 3.120 2.040 4.000 9 98% 2%
5 3.900 2.550 5.000 3 99% 1%

Abbreviations: ARDS, acute respiratory distress syndrome; COPD, chronic obstructive pulmonary disease.
a
The exact value is (1 − e−1) × 100%.

response to a step change in transrespiratory pressure.23 It is safety feature (i.e., an alarm setting) with current modes of
calculated as the product of resistance and compliance. The ventilation. When a preset high-pressure alarm threshold
value obtained is the time that takes to achieve 63% of steady is crossed, the ventilator will cycle the ventilator. The goal
state. This percent change remains a constant, regardless of is to prevent the patient from exposure to hazardous pres-
the combination of resistance and compliance. It follows that sures. Pressure cycling without an alarm is the normal oper-
each time constant will lead to a 63% decrease or increase ational state for some devices (e.g., VORTRAN automatic
in volume. In Table 3-4, one can see the difference among resuscitator).
time constants for different lung conditions. In COPD, the
time constant is longer so the time required for exhalation is
VOLUME
longer than for patients with acute respiratory distress syn-
drome. This table demonstrates the effect of the time con- Volume cycling occurs when a preset volume is reached.
stant during passive exhalation using previously published71 This occurs when the operator sets a tidal volume in vol-
expiratory time constants for three conditions (normal lung ume-control modes. Volume cycling implies that inspired
was 0.78 seconds, for acute respiratory distress syndrome volume is monitored by the ventilator’s control system dur-
0.51 seconds, and for COPD 1 second). In this example, expi- ing inspiration and compared to a threshold value (the set
ration starts from a lung volume of 500 mL above functional tidal volume). But on some ventilators, despite the setting
resting capacity. When expiratory time equals one time con- of a tidal volume, the actual cycle variable is time, that is,
stant, 63% of the tidal volume will be exhaled, leaving 37% of the time it takes to deliver the set tidal volume with the set
the tidal volume yet to be exhaled. inspiratory flow. Manufacturers seldom make this distinc-
The I:E ratio can be an operator-entered value, or just dis- tion clear in the operator’s manual.
played as a calculated value based on common scenarios for Volume cycling can also be found as a default safety
mandatory breaths: feature. In PAV + (Covidien PB 840 ventilator), one of the
cycling criteria is volume. Once the operator-preset high
• Preset I:E ratio and frequency.
inspired tidal volume limit is reached, the ventilator cycles
• Preset inspiration time (TI in seconds) and frequency
the breath and alarms.
(breaths/min). The frequency sets the ventilatory period
(1/f ) and the expiratory time is the period minus TI :
FLOW
I : E = TI : [(60 ÷ rate) − TI ] (12)
• Expiratory time and inspiratory time are fixed: Flow cycling occurs when a preset flow or percentage of
the peak flow is reached for pressure-control breaths. Flow
I : E = TI : TE (13) cycling is most commonly found with the pressure-support
Note: some ventilators will synchronize inspiration and/ mode but can be added as an “advanced setting” in other
or expiration of a mandatory breath if the patient effort is pressure-control modes on at least one ventilator (Avea,
detected in a trigger/cycle window (e.g., SIMV or APRV), CareFusion). The flow-cycling threshold preset by the oper-
which may alter the I:E from the expected value based on ator has been given many names: expiratory trigger sensi-
settings. tivity (Hamilton ventilators); trigger window (Engstrom
Ohmeda); inspiratory termination peak inspiratory flow
(Dräger Evita XL); expiratory threshold (Newport); flow ter-
PRESSURE
mination (Pulmonetics LTV ventilators); PSV cycle (Avea,
Pressure cycling occurs when the ventilator reaches a pre- CareFusion); inspiratory cycle off (Servo i, Maquet); Ecycle
set peak airway pressure. Pressure cycling is most often a (V200 respironics); and E sens (PB 840, Puritan Bennett).
 Chapter 3 Basic Principles of Ventilator Design 89

During a breath in the pressure-support mode, the flow. Flow and volume are not directly controlled during this
ventilator provides enough initial flow to achieve the set period on any current ventilator. The most common value
inspiratory pressure. The initial flow is high and then decays controlled is pressure relative to atmospheric pressure (zero-
exponentially. Some ventilators have a preset default value gauge pressure).
for flow cycling (range: 5% to 30% of peak inspiratory flow);
others allow the operator to adjust it (range: 1% to 80% of
peak inspiratory flow). Only one device (e500, Newport Positive End-Expiratory Pressure
Medical, Costa Mesa, CA) has automatic adjustment of the
flow-cycling criteria. This device has a proprietary algorithm The PEEP is established by the ventilator exhalation valve. A
called FlexCycle. It will change the cycle criterion from common source of confusion is the term continuous positive
10% to 50% of peak flow based on measurements of airway airway pressure versus PEEP. Continuous positive airway
pressure, the expiratory time constant, and expert-based pressure is generally considered to be a mode on mechanical
rules applied through a closed-loop system.72 ventilators (or a mode of treatment for sleep apnea), whereas
A default cycle criterion of 25% to 30% of the peak PEEP is the elevation of the baseline pressure during any
flow seems inappropriate as a “fit all” measure. The goal mode of ventilation and is generally a setting for a mode. Until
of adjusting the flow-cycling criterion is to avoid expira- recently, the selection of PEEP has been a relatively arbitrary
tory asynchrony.59 In expiratory asynchrony, the ventila- process and the meaning of “optimum PEEP” is debatable.77
tor ends inspiration before or after the patient inspiratory Now, Hamilton Medical has developed the INTELLiVENT
effort. We must remember that flow is a manifestation of the system for the G5 ventilator that uses an algorithm for auto-
respiratory system characteristics, respiratory muscle effort matic targeting of PEEP and FIo2. A closed-loop algorithm
(inspiratory and expiratory) and the integrity of the lung- based on expert rules defines the response of the ventilator
ventilator circuit. If the respiratory system has a prolonged to measured ventilation variables, end-tidal carbon dioxide
time constant, a standard flow-termination criterion may be and pulse oximetry.
inappropriate as it will prolong inspiration. That may be the
case for patients with COPD, where the standard criterion of P-Low. P-low is one of the settings entered for so-called
25% may be too low, and lead to expiratory asynchrony and “bilevel” modes like APRV (Fig. 3-21). P-low is just another
increased work of breathing.73,74 Finally, a leak in the ventila- name for PEEP. Similar to PEEP, the settings are dependent
tor circuit (mask) or in the patient (endotracheal cuff or a on the user. There is, however, a large discrepancy with
bronchopleural fistula) may lead to lack of decay in the flow the objective of PEEP. In APRV, P-low is set to zero.78 The
curve and thus asynchrony.72 goal is to maintain lung recruitment with the use of auto-
Figure 3-16 illustrates an algorithm that can be used to PEEP induced by short T-low settings. P-low can also be set
adjust the flow-cycle threshold to improve patient–ventilator based on the biphasic model,79 where complete exhalation is
synchrony.62 allowed and P-low is then set with the same goals as PEEP.

DIAPHRAGMATIC SIGNAL Expiratory Time. Expiratory time is defined as the period

from the start of expiratory flow to the start of inspiratory
One goal of mechanical ventilation is to improve the patient– flow. As stated above, the expiratory time is commonly
ventilator synchrony. In a perfect setting, the beginning and dependent on the set inspiratory time, and set respiratory
end of an assisted breath would be correlated with the neural rate. It is rarely a fixed value. This occurs because making it
signal driving the inspiratory muscles. In conventional venti- a fixed value would produce, in most modes, changes in the
lation that is rarely the case.75 NAVA attempts to achieve this inspiratory phase (inspiratory time, flow, and pressure). The
goal with the use of an electromyogram signal obtained from most common exception to this is on ventilators that offer
the diaphragm (Edi). As diaphragmatic activity decreases, some form of APRV/biphasic pressure-control mode where
so does the amplitude of the Edi curve. When it decreases expiratory time is set as “T-low.”
below 70% of the peak signal (or 40% when the peak value is
low), inspiration is cycled off. As a safety feature there is also T-Low. With exception of APRV/biphasic, in all the modern
a time-cycling mechanism. Piquilloud et al compared NAVA modes of ventilation the expiratory time is dependent on
versus pressure support with the usual cycling criteria and the inspiratory time and frequency; it is not an operator-set
found a significant improvement in expiratory synchrony value. In APRV/biphasic, the operator sets the time spent
(see Fig. 3-18).76 at lower pressure, that is, exhalation (see Fig. 3-21). T-low
can be set by the operator based on the peak expiratory
flow,78 targeting exhaled tidal volume or allowing complete
Baseline Variables exhalation.80 Setting T-low sets the time trigger threshold
for mandatory breaths. Among the methods described in
The baseline variables are the variables controlled during setting T-low in APRV, targeting percent of peak expiratory
the expiratory time. Expiratory time is the period from the flow (%PEF) is perhaps the most promoted method. The
beginning of expiratory flow to the initiation of inspiratory goal is to set the T-low short enough to avoid full exhalation,
90 Part II Physical Basis of Mechanical Ventilation

Airway pressure release ventilation

Volume

Pressure

Phigh and Thigh Plow and Tlow Thigh : Tlow = 4:1

Biphasic positive airway pressure

Phigh and Thigh Plow and Tlow Thigh : Tlow = 1:1–4

FIGURE 3-21 Differences in P-low and T-low settings for airway pressure release ventilation and biphasic positive airway pressure. Notice the
difference in I:E ratio. The operator enters P-high, P-low, T-high, and T-low. The patient may breath spontaneously. Green curves show flow and blue
curves show inspiratory effort.

thereby generating air trapping.29 Adjusting T-low on the Level 4 events are based entirely on patient condition.
ventilator to manually maintain %PEF at 50% to 75% may They may include events such as changes in gas exchange,
be a tedious process, which may seem simple on paper, but dead space, oxygenation, and cardiovascular functions.
in a spontaneously breathing patient can become a true Ventilators generally monitor these events and exter-
challenge. Newer ventilators, like the Dräger Evita Infinity nal monitors are required for alarms (the exception being
V500, have attempted to make the process easier by allowing exhaled carbon dioxide-level alarms built into the ventilator
the operator to set a trigger threshold based on a percentage display).
of peak expiratory flow. Currently, ventilators do not display alarm settings
as levels of priority. Instead, they tend to lump them all
together on one screen that shows alarm limits and controls
Alarms for changing them (Fig. 3-22). How to set alarm thresholds
is a complicated topic that has been studied but for which
Ventilator alarms bring unsafe events to the attention of the little information is available regarding mechanical venti-
clinician. Events are conditions that require clinician aware- lation. The goal is to minimize false alarms and maximize
ness or intervention. Events can be classified according to true alarms. A high false alarm rate leads to clinician habit-
their level of priority.81 uation and can also lead to inappropriate responses. In a
Immediately life-threatening events are classified as Level recent study of an intensive care unit, 1214 alarms occurred
1. They include conditions like insufficient or excessive gas and 2344 tasks were performed. On average, alarms
delivery to the patient, exhalation valve failure, control cir- occurred six times per hour; 23% were effective, 36% were
cuit failure, or loss of power. Level 1 alarm indicators should ineffective, and 41% were ignored.82 In another intensive
be mandatory (cannot be turned off by the operator), redun- care unit study, alarms occurred at a rate of six per hour.
dant, and noncanceling. Approximately 40% of the alarms did not correctly describe
Level 2 events range from mild irregularities in machine the patient condition and were classified as technically false;
function to dangerous situations that could threaten patient 68% of those were caused by manipulation. Shockingly, only
safety if left unattended. Some examples are failure of the 885 (15%) of all alarms were considered clinically relevant.83
air–oxygen blending system, inadequate or excessive PEEP, Although these studies did not address mechanical venti-
autotriggering, circuit leak, circuit occlusion, inappropriate lator alarms specifically, it is not hard to imagine similar
I:E ratio, and failure of the humidification system. Alarms in results for such a study.
this category may be self-canceling (i.e., automatically turned Ventilator alarms are usually set by the operator as either
off if the event ceases) and are not necessarily redundant. an arbitrary absolute value or a percentage of the current
Level 3 events indicate changes in the amount of ventila- value. Examples would be airway-pressure alarms (high
tor support provided to the patient consequent to changes in and low) set at the current value plus or minus 5 cm H2O
the patient’s ventilatory drive or respiratory system mechan- or low and tidal volume/minute ventilation set at plus or
ics and the presence of auto-PEEP. These events often trigger minus 25% of the current value.81 The problem is that the
the same alarms as Levels 1 and 2. parameters for which alarms are important, and these three
 Chapter 3 Basic Principles of Ventilator Design 91

FIGURE 3-22 Alarm screen from the G5 ventilator. (Reproduced, with permission, from Hamilton Medical.)

in particular, are highly variable, with significant portions so that, for example, significant events or gradual changes in
at extreme values.84 Thus, limits set as absolute values or patient condition can be identified (Fig. 3-24). In addition,
percentages may reduce safety for some extreme values ventilators often provide an alarm log, documenting such
while increasing nuisance events for other values. An alter- things as the date, time, alarm type, urgency level, and events
native approach might be a type of “smart alarm,” whereby associated with alarms, for example, when activated and
the alarm limits are automatically referenced to the current when canceled. Such a log could be invaluable in the event of
value of the parameter such that extreme values have tighter a ventilator failure leading to a legal investigation.
limits. Further research is needed to identify optimiza-
tion algorithms (i.e., minimize both harmful and nuisance
WAVEFORMS AND LOOPS
events).
Many ventilators display waveforms (sometimes called “sca-
lars”) of airway pressure, volume, and flow as functions of
VENTILATOR OUTPUTS (DISPLAYS) time. Such displays are useful for identifying the effects of
changes in settings or mechanics on the level of ventilation.85
Display Types They are also very useful for identifying sources of patient–
ventilator asynchrony, such as missed triggers, flow asyn-
Ventilator output displays represent the values of monitored chrony, and delayed or premature cycling.86 They can also
parameters that result from the operator settings. There are display one variable against another as an x-y or “loop” dis-
four basic ways to present the monitored data: as numbers, as play. The most common loop displays show pressure on the
waveforms, as trend lines, and in the form of abstract graphic horizontal axis and volume on the vertical axis, or volume
symbols. on the horizontal axis and flow on the vertical axis. Pressure-
volume loop displays are useful for identifying optimum
PEEP levels (quasistatic loops only) and over distension.
NUMERIC VALUES
Flow-volume loops are useful for identifying the response to
Data are most commonly represented as numeric values such bronchodilators. Figure 3-25 is an example of a composite
as FIo2, peak, plateau, mean and baseline airway pressures, display showing numeric values, waveforms, and loops.
inhaled/exhaled tidal volume, minute ventilation, and fre-
quency. Depending on the ventilator, a wide range of calcu-
ADVANCED GRAPHICS
lated parameters may also be displayed including resistance,
compliance, time constant, airway occlusion pressure at 0.1 As ventilators have become more complex, their displays have
second (P0.1), percent leak, I:E ratio, and peak inspiratory/ become more confusing and difficult to use. A recent trend is
expiratory flow (Fig. 3-23). to move away from the traditional display screens in favor of
a more integrative approach using creative graphic elements.
For example, one study showed that observers detected and
TRENDS
treated obstructed endotracheal tubes and auto-PEEP prob-
Many ventilators provide trend graphs of just about any lems faster with graphical rather than conventional displays.
parameter they measure or calculate. These graphs show how They also reported significantly lower subjective workloads
the monitored parameters change over long periods of time, using the graphical display.87
92 Part II Physical Basis of Mechanical Ventilation

PED/ 30-06-2011 13:50

INFANT
BPRV-SIMV
M
21.0 0.21 1.3 40 19 AUTO
Waves
Ppeak FIo2 Cdyn RRtot VTI Slope/
effective mL rise
M
19.5 1:5.9 1.7 0 17 AUTO Loops
Pplat I:E Cstat RRspont VTE Exp
[13:48] [13:48] mL thresh
Numeric
10.7 12 -- 0 11 OFF
Pmean Insp flow Rl RSBI VTE pause
[ ] %variance sec Trends
7.7 24 -- 0.34 0.9 ON
PEEP Exp flow RE tlnsp MVI Open
[ ] Save
exh

8.6 0.00 -- 0.00 0.71 Mechanic

Weaning
total PEEP WOBim Time MVE spont MVE Flow Advanced
[13:48] const. wave Basic

FIGURE 3-23 Digital display of monitored and calculated parameters from the Newport e360 ventilator. (Reproduced, with permission, from
Newport Medical.)

Hamilton Medical was the first to make use of innova- pre-spontaneous breathing trial (SBT), SBT in progress,
tive picture graphics on their G5 ventilator. They created and post-SBT phase.
a graphic representation of the lungs, called a “dynamic Dräger Medical recently introduced a similar graphic
lung panel,” that visually displays information about resis- display called “Smart Pulmonary View.” The shapes of the
tance and compliance by the shape and color of the lungs graphic elements quickly indicate relative values of respira-
and airways (Fig. 3-26). This panel is supplemented by a tory system resistance and compliance as well as the balance
unique graphic, called the “vent status panel,” which dis- between mandatory and spontaneous breaths (Fig. 3-27).
plays key parameters (e.g., oxygenation, ventilation, and Digital values are also displayed.
spontaneous breathing activity). Furthermore, the display
shows when each item is in or out of an acceptable zone
and for how long. This makes weaning status easy to iden- THE FUTURE
tify. Preliminary data88 suggest that this display reduces the
time required for clinicians to identify common problems,
for example, normal, restrictive, and obstructive lungs;
Better Operator Interfaces
occluded endotracheal tube, right main-stem intubation, As modes have become more complex, the operator
interfaces on ventilators with computerlike displays has
become cumbersome. Multiple options for control settings
tend to get lost in layers of different screen views. Worse,
screen views are often customizable such that if strict con-
trol is not exerted by an individual hospital department,
each ventilator will be “stylized” by individual operators
and chaos will ensue. Clearly, flexibility is a double-edged
sword.
Very few studies have been published on ease of use or
the problems with current displays. We need to identify
optimal ways for ventilator displays to provide three basic
functions: to allow input of control and alarm parameters,
to monitor the ventilator’s status, and to monitor the ven-
tilator–patient interaction status. There is a long way to
go before the user interface provides an ideal experience
FIGURE 3-24 Trend display from the Avea ventilator. (Reproduced, with these functions. This may be a fruitful area of future
with permission, from CareFusion.) research.6,8
 Chapter 3 Basic Principles of Ventilator Design 93

SIMV Adult

AutoFlow

.700 Paw-V 50 V-Flow Pmean PEEP

Freece Values

.500 25 10 5
0 Main
.300 Single Vol.% FIo2
blech
-25
Data...
.100
0
–10 0 20 40 cm H2O
-50
0 .200 .400 .600 L
Ref.
35 Special
Flow Procedure...
L/min L/min MV
50

25
4.5
0
L/min MVspn
–25

–50 0
.700 L bpm Ftotal
V
.500
10
.300
L VTi
.100
0
0 2 4 6 8 10 12 14 16 Sec
.450
Apnea-vent. On 1.0: 2.5
35 .450 1.7 10 5 0
Ext.
I:E 02 VT Tinsp f PEEP Psupp Int.

FIGURE 3-25 An example of both scalar and loop displays. (Reproduced with permission from Draeger Medical GmbH, Luebeck, Germany.)

Better Patient Interfaces Certainly, humidification systems using heated wires and
automatic-temperature control have evolved, but we still
The interface between a modern ventilator and the patient are not capable of measuring and directly controlling a pri-
is a piece of plastic tubing, that is, the “patient circuit,” mary variable of gas conditioning: humidity. Indeed, after
whose design has not changed much in several decades. all this effort at evolving humidification systems, there are
data to show that simple, unheated circuits provide better
humidification of inspired gas.89 In addition, the compli-
ance of the patient circuit degrades the accuracy of flow
delivery and must be “compensated” for by complex math-
ematical algorithms. It seems to us that a major revolu-
tion in patient-interface design would be to simply make
the patient circuit a permanent part of the ventilator and
treat water molecules the way we treat molecules of oxygen,
nitrogen, helium, and nitric oxide. But to do this, ventilator
manufacturers would have to merge with humidifier manu-
facturers and collaborate in systems design rather than see-
ing the patient circuit and humidifier as devices separate
from the ventilator (see Chapter 2).

Better Targeting Systems

Chapter 2 provides a conceptual framework and sugges-
tions for better targeting systems of the future. In essence,
FIGURE 3-26 Example of picture graphic display from the Hamilton evolution in this area involves more and better sensors and
G5 ventilator showing the dynamic lung panel and the vent status panel. the software algorithms required to manage the data they
(Reproduced, with permission, from Hamilton Medical.) provide. The clear trend here, both in basic research and
94 Part II Physical Basis of Mechanical Ventilation

12:58:43
VC-SIMV
PS
AutoFlow

R 13.8 Cdyn mL/mbar

0 15.2 mbar/L/s B

45.7
Cdyn 45.7 Take
reference

11-Nov-2010
120 12:34:25 Rpat mbar/L/s
mL/mbar R 7.6
VT
Spon
Mand
Cdyn 79
9.3
VTe mL
D
760
MVe L/min
RR
C
8.88 12.00
2.00

A FIo2 Vol%

21
FIGURE 3-27 Example of picture graphic display from the Dräger Evita Infinity V500 ventilator showing the Smart Pulmonary View. A. The move-
ment of the diaphragm indicates synchronized mandatory breaths or supported (triggered) breaths. B. The blue line around the trachea indicates the
resistance R. The higher the resistance, the thicker the line. The numeric value is also displayed. C. The blue line around the lungs indicates the com-
pliance Cdyn. The higher the compliance, the thinner the line. The numeric value is also displayed. D. Diagram displaying the relationship between
spontaneous breathing and mandatory ventilation. The following parameters are displayed in different colors: spontaneous tidal volume (VT spon),
spontaneous respiratory rate (RR spon), mandatory tidal volume (VT mand), and mandatory respiratory rate (RR mand). (Reproduced, with permis-
sion, from Draeger Medical GmbH, Luebeck, Germany.)

commercial applications, is to develop “closed-loop” target- CO2 monitoring and pulse oximetry. These extra data,
ing systems based on mathematical models of physiologic along with advanced targeting software algorithms, allow
processes, or artificial intelligence, or combinations thereof, the ventilator to automatically select and adjust minute
with the goal of automating the moment-to-moment adjust- ventilation, PEEP, and FIo2. This makes INTELLiVENT
ment of ventilator output to patient needs. The best example “… the world’s first complete closed-loop ventilation solu-
so far is a mode called INTELLiVENT-ASV (G5 ventilator, tion that offers automated adjustment of oxygenation and
Hamilton Medical) and is currently available only in Europe. ventilation.”90
This mode is an improvement on the optimal target- Along with the new targeting systems, this mode also
ing scheme that is the basis of the mode called ASV (see provides a unique operator interface that Hamilton refers
Chapter 2). Like ASV, INTELLiVENT-ASV is a form of to as the “Ventilation Cockpit,” an apparent reference to the
pressure control intermittent mandatory ventilation using “autopilot” feature in airplanes. The interface is designed
adaptive-pressure targeting to automatically adjust inspi- to facilitate understanding complex information in a visu-
ratory pressure to maintain a target tidal volume, which, ally intuitive way. In addition to displaying the usual digi-
in turn, is selected by an optimization model. An “optimal” tal parameters and waveforms, the new mode offers several
targeting scheme attempts to either maximize or minimize other screens. The “Dynamic Lung” screen integrates data
some performance metric.49 In the case of ASV, the venti- on lung mechanics, end-tidal carbon dioxide (PETCO2),
lator attempts to select a tidal volume and frequency (for and pulse oximetry (SpO2), and offers a metric called the
passive ventilation) that minimizes the work rate of ven- “heart–lung interaction” index (Fig. 3-28). A graphic ele-
tilation for the patient’s particular state of lung mechan- ment called the “Ventilation Map” plots PETCO2 against peak
ics. As the lung mechanics change, the ventilatory pattern airway pressure as shown in Figure 3-29. Another display,
changes. ASV requires that the operator input the patient’s the “Oxygenation Map,” is very similar to the Ventilation
weight, however, so that the ventilator can calculate an esti- Map: it provides detailed information about the oxygen-
mated minute ventilation requirement. The operator must ation status based on the major physiologic input, as mea-
also manage PEEP and FIo2. INTELLiVENT-ASV takes sured by pulse oximetry (SpO2), and the resulting treatment
ASV a step further by adding input data from end-tidal (PEEP/FIo2).
 Chapter 3 Basic Principles of Ventilator Design 95

records and move us closer to integration of vast amounts of

data into useful information for measurable improvements
in patient outcomes. This process, however, will present
significant challenges to vendors and end users to develop
standardized vocabularies, taxonomies, and data transfer
protocols in order to assure higher levels of accuracy, secu-
rity, and usability.

REFERENCES
1. McPherson SP, Spearman CB. Respiratory Therapy Equipment. St.
Louis, MO: CV Mosby; 1977.
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