Review Article

Basic Invasive Mechanical VentilationBenjamin D. Singer, MD, and Thomas C. Corbridge, MD

Abstract: Invasive mechanical ventilation is a lifesaving interven-tion for patients with respiratory failure. The most commonly usedmodes of mechanical ventilation are assist-control, synchronizedintermittent mandatory ventilation, and pressure support ventilation.When employed as a diagnostic tool, the ventilator provides data onthe static compliance of the respiratory system and airway resis-tance. The clinical scenario and the data obtained from the ventilatorallow the clinician to provide effective and safe invasive mechanicalventilation through manipulation of the ventilator settings. Whilelife-sustaining in many circumstances, mechanical ventilation mayalso be toxic and should be withdrawn when clinically appropriate.

Key Words: assist-control ventilation, mechanical ventilation, pres-sure support ventilation, synchronized intermittent mandatory ven-tilation, ventilator weaning

The need for mechanical ventilation is a frequent reasonfor admission to an intensive care unit. Mechanical ven-

tilation following endotracheal intubation is often used toimprove pulmonary gas exchange during acute hypoxemic orhypercapnic respiratory failure with respiratory acidosis.1 Me-chanical ventilation also redistributes blood flow from work-ing respiratory muscles to other vital organs and is thereforea useful adjunct in the management of shock from any cause.

This article will review basic invasive mechanical ven-tilator modes and settings, the use of the ventilator as a di-agnostic tool, and complications of mechanical ventilation.Weaning and extubation will also be discussed.

Ventilator BasicsOnce the trachea has been successfully intubated and

proper endotracheal tube placement has been verified by clin-ical and radiographic means, ventilator settings must be se-lected.2 The first parameter to be chosen is the ventilatormode.3 The mode determines how the ventilator initiates a

breath, how the breath is delivered, and when the breath isterminated. Despite the availability of several new modes ofventilator support, time-tested modes such as assist-control(AC), synchronized intermittent mandatory ventilation(SIMV), and pressure support ventilation (PSV) are the mostcommonly used and the focus of this review.

Assist-Control

Assist-control is a commonly used mode of mechanicalventilation in medical intensive care units. A key concept inthe AC mode is that the tidal volume (VT) of each deliveredbreath is the same, regardless of whether it was triggered bythe patient or the ventilator. At the start of a cycle, the ven-tilator senses a patient’s attempt at inhalation by detectingnegative airway pressure or inspiratory flow. The pressure orflow threshold needed to trigger a breath is generally set bythe respiratory therapist and is termed the trigger sensitivity.4

From the Department of Medicine, Northwestern University, Feinberg Schoolof Medicine; and Division of Pulmonary and Critical Care Medicine,Northwestern University, Feinberg School of Medicine, Chicago, IL.

Reprint requests to Benjamin D. Singer, MD, Department of Medicine, North-western University, 251 East Huron Street, Galter Suite 3-150, Chicago,IL 60611. Email: bsinger007@md.northwestern.edu

Accepted March 22, 2009.

Copyright © 2009 by The Southern Medical Association

0038-4348/0�2000/10200-1238

Key Points• Assist-control is a patient- or time-triggered, flow-

limited, and volume-cycled mode of mechanical ven-tilation.

• Synchronized intermittent mandatory ventilation issimilar to assist-control mode except that breaths takenby the patient beyond those delivered by the ventilatorare not supported; pressure support may be added tothese breaths to augment their volumes.

• Simple math using data obtained from the ventilatormay be used to calculate the inspiratory-to-expiratorytime ratio, the static compliance of the respiratorysystem, and the airway resistance.

• An increase in peak inspiratory pressure without aconcomitant increase in plateau pressure suggests anincrease in airway resistance, while an increase inboth peak inspiratory and plateau pressure suggests adecrease in the static compliance of the respiratorysystem.

• The mechanical ventilator, while lifesaving in manycircumstances may also be toxic and should be with-drawn as soon as clinically appropriate; a spontaneousbreathing trial helps to identify those patients whomay be successfully extubated.

1238 © 2009 Southern Medical Association

If the patient does not initiate a breath before a requisiteperiod of time determined by the set respiratory rate (RR), theventilator will deliver the set VT. For example, if RR is set at12 breaths per minute and the patient is not initiating breaths,

the ventilator will deliver a breath every 5 seconds; this iscalled time-triggering. Similarly, if RR is 15 breaths perminute, the ventilator will deliver a breath every 4 seconds.However, if the patient initiates a breath, the ventilator in ACmode will deliver the set VT; these breaths are patient-trig-gered rather than time-triggered.

Regardless of whether the breath is patient-triggered ortime-triggered, the exhalation valve closes and the ventilatorgenerates inspiratory flow at a set rate and pattern. The pa-tient is limited to that flow rate and pattern during inhalation.Flow may be either constant (square waveform) or deceler-ating (ramp waveform) (Fig. 1).5 A square waveform is gen-erally selected when inspiratory time is to be minimized thusallowing more time for exhalation (ie obstructive lung dis-eases). Ramp waveforms are useful for ventilating a hetero-geneous lung, such as in the acute respiratory distress syn-drome (ARDS). Often the flow rate and pattern are selectedto maximize patient comfort and patient-ventilator synchrony.Inspiratory flow lasts until the set VT is delivered at whichtime the breath is “cycled-off” (and so the term volume-cy-cled mechanical ventilation).

Thus, the AC mode is patient- or time-triggered, flow-limited, and volume-cycled. An important correlate to thismode is that the airway pressures generated by chosen ven-tilator settings are determined by the compliance of the re-spiratory system and the resistance of the airways.

When the exhalation valve opens, the patient is allowedto exhale passively or actively until the airway pressurereaches end-expiratory pressure. This pressure is typically set

Fig. 1 Flow-pressure waveforms. The left tracing represents aconstant or square waveform. When flow is delivered at a con-stant rate, resistive pressure remains fairly constant (reflectingconstant flow) while distending pressure increases with deliveryof the tidal breath. In the tracing on the right, a decelerating orramp waveform is shown. Since flow is decreasing, resistive pres-sure decreases as distending pressure increases. The net effect isan essentially constant pressure during the tidal breath.

Fig. 2 Assist-control (AC) mode. Flow, pressure, and volume tracings of three separate breaths are presented. The first two breathsare initiated by the patient (patient-triggered) via a drop in airway pressure (circled). The breath is delivered by constant flow(flow-limited), shown as a rapid increase in flow to a preset level. Flow lasts until a preset tidal volume (VT) is reached (volume-cycled).The exhalation port of the ventilator then opens and the patient passively or actively exhales. In the third breath, the preset backuptime limit is met (the patient did not initiate a breath) and the ventilator delivers the breath (time-triggered). Note that patient-triggered and time-triggered breaths deliver the same inspiratory flow and tidal volume in the assist-control mode.

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slightly higher than atmospheric pressure to prevent atelec-tasis, decrease inspiratory work of breathing, or improve gasexchange depending on the clinical scenario. This positiveend-expiratory pressure (PEEP) is generated by a resistor inthe exhalation port of the ventilator (Fig. 2).6

AC mode has several advantages including low work ofbreathing, as every breath is supported and tidal volume isguaranteed.7,8 However, there is concern that tachypnea couldlead to hyperventilation and respiratory alkalosis. “Breathstacking” can occur when the patient initiates a second breathbefore exhaling the first. The results are high volumes andpressures in the system. Hyperventilation and breath stackingcan usually be overcome by choosing optimal ventilator set-tings and appropriate sedation.

Synchronized Intermittent Mandatory Ventilation

Synchronized intermittent mandatory ventilation (SIMV)is another commonly used mode of mechanical ventilation(Fig. 3).9,10 Like AC, SIMV delivers a minimum number offully assisted breaths per minute that are synchronized withthe patient’s respiratory effort. These breaths are patient- ortime-triggered, flow-limited, and volume-cycled. However,any breaths taken between volume-cycled breaths are notassisted; the volumes of these breaths are determined by thepatient’s strength, effort, and lung mechanics.11 A key con-cept is that ventilator-assisted breaths are different than spon-

taneous breaths. Another important concept is that AC andSIMV are identical modes in patients who are not spontane-ously breathing due to heavy sedation or paralysis. High re-spiratory rates on SIMV allow little time for spontaneousbreathing (a strategy very similar to AC), whereas low respi-ratory rates allow for just the opposite.

SIMV has been purported to allow the patient to “exer-cise” their respiratory musculature while on the ventilator byallowing spontaneous breaths and less ventilator support.12,13

However, SIMV may increase work of breathing and causerespiratory muscle fatigue that may thwart weaning and ex-tubation.

Pressure Support Ventilation

A common strategy is to combine SIMV with an addi-tional ventilator mode known as pressure support ventilation(PSV) (Fig. 4).14 In this situation, inspiratory pressure is addedto spontaneous breaths to overcome the resistance of the en-dotracheal tube or to increase the volume of spontaneousbreaths. PSV may also be used as a stand-alone mode tofacilitate spontaneous breathing.

PSV mode is patient-triggered, pressure-limited, andflow-cycled. With this strategy, breaths are assisted by a setinspiratory pressure that is delivered until inspiratory flowdrops below a set threshold. When added to SIMV, PSV isapplied only to the spontaneous breaths taken between vol-

Fig. 3 Synchronized intermittent mandatory ventilation (SIMV) mode. As in assist-control mode, mandatory breaths are patient-triggered, flow-limited, and volume-cycled. However, breaths taken between mandatory breaths (bracketed) are not supported. Rate,flow, and volume are determined by the patient’s strength, effort, and lung mechanics.

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ume-guaranteed (volume-cycled) breaths. During PSV alone,all breaths are spontaneous. Airway pressures drop to the setlevel of PEEP during exhalation and rise by the amount ofselected pressure support during inhalation. RR and VT aredetermined by the patient; there is no set RR or VT.

Setting and Using the VentilatorRoutine initial ventilator settings are shown in the Ta-

ble.15–18 These settings are aimed at achieving a safe orsupranormal level of oxygenation and a relatively normalpartial pressure of arterial carbon dioxide (PaCO2) in the peri-

intubation period. This may not always be desirable. Forexample, a higher initial respiratory rate should be chosen fora patient with severe metabolic acidosis and preintubationrespiratory compensation. Subsequent ventilator changes arebased on the clinical scenario, arterial blood gas measure-ments, and calculations of the static compliance of the respi-ratory system and airway resistance (see below). For exam-ple, a low VT on the order of 6 mL/kg predicted body weightis beneficial in ARDS,19 and prolongation of expiratory timeis recommended in status asthmaticus.20 To improve oxygen-ation, the fraction of inspired oxygen (FiO2) and/or PEEPmay be increased. PEEP improves oxygenation by preventingalveolar collapse and decreasing intrapulmonary shunt.6 Toincrease ventilation, VT and/or RR may be increased.

Inspiratory and Expiratory Times

Simple math may be used to calculate total cycle time,inspiratory time, and expiratory time during delivery of anassisted breath. The total cycle time (also referred to as therespiratory cycle time) equals inspiratory time plus expiratorytime (Fig. 5). It is determined by—and inversely related to—RR. For example, if RR is 12 breaths per minute and thepatient is not breathing above the set rate, the total cycle timeis 5 seconds; if RR is 20 breaths per minute, the total cycletime is 3 seconds. Inspiratory time is determined by VT and

Fig. 4 Synchronized intermittent mandatory ventilation plus pressure support ventilation (SIMV � PSV) mode. The first and lastbreath tracings are identical to those seen in SIMV. However, during pressure-supported breaths (bracketed), the ventilator deliversa set inspiratory pressure which is terminated when the flow drops below a set threshold. Spontaneous breaths are patient-triggered,pressure-limited, and flow-cycled.

Table. Initial ventilator settingsa

Parameter Setting

Mode AC or SIMV

FiO2 1.0

VT 8–10 mL/kg

RR 10–12 breaths/min

V̇i60 L/min

PEEP 5 cm H2O

aAC, assist-control; SIMV, synchronized intermittent mandatory ventilation;FiO2, fraction of inspired oxygen; VT, tidal volume; mL/kg, milliliters perkilogram; RR, respiratory rate; V̇i, inspiratory flow rate; L, liters; PEEP,positive end-expiratory pressure; cm H2O, centimeters of water.

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the inspiratory flow rate (V̇i). For example, if VT is 1000milliliters and inspiratory flow is 60 liters per minute (1 literper second), then inspiratory time is 1 second. These conceptscan be used to calculate the inspiratory-to-expiratory time(I:E) ratio (Fig. 6).

Auto-PEEP. Incomplete emptying of alveolar gas at theend of exhalation elevates alveolar pressure relative to airwayopening (mouth) pressure, a state referred to as auto-positiveend-expiratory pressure or auto-PEEP. This occurs when pa-tient expiratory times are longer than the allotted expiratorytime (as occurs in obstructive lung disease)21 and is signaledby persistent expiratory flow at the time the next breath isdelivered (Fig. 7, A). Auto-PEEP is measured by performingan expiratory hold maneuver (Fig. 7, B). Consequences ofauto-PEEP include decreased cardiac preload and increasedwork of breathing since auto-PEEP must be overcome by thepatient to trigger a breath. A common strategy to decreaseauto-PEEP is to prolong expiratory time. This may be ac-complished by decreasing RR, which runs the risk of increas-ing PaCO2. Hypercapnia may be tolerated in a strategy of“permissive hypercapnia” provided sudden and severechanges in pH and PaCO2 are avoided.22 Increasing the in-spiratory flow rate may further prolong expiratory time, al-though at the cost of higher peak inspiratory pressure (PIP).In severe cases of auto-PEEP signaled by hypotension, tachy-cardia, and high airway pressures, disconnecting the patientfrom the ventilator and manually decompressing the thoraxmay be necessary to restore hemodynamic stability.

Measuring Compliance and Resistance

As mentioned above, pressures generated during tidalvolume delivery are influenced by the compliance of therespiratory system and airway resistance. These values maybe estimated by performing an inspiratory hold maneuver(Fig. 8).

Since compliance is the differential change in volume fora given change in pressure (C � dV/dP), the static compli-ance of the respiratory system (Cstrs) can be calculated by

Cstrs �VT

Pplat – PEEPtotal

Normal compliance in a mechanically ventilated patientis 60–80 mL/cm H2O. Low compliance is common in pul-monary edema, interstitial lung disease, lung hyperinflation,pleural disease, obesity, and ascites. In patients with low Cstrs,the plateau pressure (Pplat) is higher for any set VT. To de-crease the risk of over-inflation lung injury (termed vo-lutrauma), a common recommendation is to keep Pplat lessthan 30 cm H2O by lowering VT and avoiding excess PEEP.Note that interventions that increase Cstrs invariably favorweaning and return to spontaneous breathing.

Resistance is pressure divided by flow. Thus airway re-sistance (Raw) is calculated by

Raw �PIP – Pplat

V̇i

Normal airway resistance is less than 15 cm H2O/L/s.Increased airway resistance suggests kinking or plugging of

Fig. 5 Flow tracing showing components of a breath. Totalcycle time (TCT), which is set by the respiratory rate, is the sumof inspiratory time (tI) and expiratory time (tE).

Fig. 6 How to determine the inspiratory-to-expiratory time ra-tio. In the above example, the patient is breathing 20 times perminute. Thus, the total cycle time is 3 seconds (60 seconds perminute divided by 20 breaths per minute). A 1-liter tidal volumedelivered at 60 liters per minute (1 liter per second) takes 1second to deliver, leaving 2 seconds available for exhalation. Theventilator inspiratory-to-expiratory time ratio (I:E) is thus 1:2.Importantly, patient expiratory time may be shorter or longerthan the amount of time allotted. In the above example thepatient completes exhalation (as signaled by a return of expira-tory flow to baseline) well before the next breath is delivered.Abbreviations: tI, inspiratory time; tE, expiratory time; L/min,liters per minute; cm H2O, centimeters of water; L, liters; s,seconds.

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the endotracheal tube, intraluminal mucus, or bronchospasm.Interventions that lower Raw further benefit spontaneousbreathing.

A change in PIP is a common diagnostic problem in amechanically ventilated patient. Decreased PIP is usually dueto an air leak in the ventilator circuit. Increased PIP (causingthe ventilator to alarm) should be investigated initially byphysical exam and by performing an inspiratory hold maneu-ver. An increase in PIP without a concomitant increase inPplat suggests increased airway resistance and the need toevaluate the patency of the endotracheal tube and the need forbronchodilators. An increase in both PIP and Pplat suggestsdecreased compliance of the respiratory system. Figure 9shows a differential diagnosis of an increased PIP.

Complications of Intubation andMechanical Ventilation

Numerous complications of intubation and mechanicalventilation may arise. Toxic effects of lung over-inflation(volutrauma) include pneumothorax and acute lung injury.Volutrauma is minimized by adjusting the ventilator set-

tings—particularly VT and PEEP—to keep Pplat less than 30cm H2O. Oxygen toxicity is proportional to the duration oftime that the patient is exposed to FiO2 greater than 0.6.Cardiac output may be increased or decreased based on thepreload- and afterload-reducing effects of positive pressureventilation.

Ventilator-associated pneumonia (VAP) develops at arate of approximately 1% per day and has an attributablemortality rate as high as 20–50%.23 Hand washing, elevationof the head of the bed, non-nasal intubation, and proper nu-trition all reduce the rate of VAP. Avoidance of unnecessaryantibiotics decreases the risk of VAP with a resistant patho-gen.

Complications from the endotracheal tube itself includehard and soft palate injuries, laryngeal dysfunction, trachealstenosis, tracheomalacia, and near-fatal or fatal obstruction.

Weaning from the VentilatorIn light of these serious complications, it is important to

frequently assess the need for continued intubation and me-chanical ventilation.24 “Weaning” or “liberating” patients

Fig. 7 A. Persistence of end-expiratory flow in the setting of auto-positive end-expiratory pressure (auto-PEEP). Auto-PEEP isend-expiratory pressure above that generated by the ventilator. It is due to inadequate expiratory time before the next breath isdelivered. Note that auto-PEEP generates persistent flow at the end of exhalation compared to the desired scenario in which flowreturns to zero before the next breath is initiated. B. The expiratory hold maneuver. At the end of exhalation, the expiratory port isoccluded allowing for equilibration of alveolar and airway opening pressures. The pressure measured at the airway opening minusset PEEP is auto-PEEP.

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from the ventilator begins by identifying patients who canbreathe spontaneously. Patients with reversed sedation, stablevital signs, minimal secretions, and adequate gas exchangeare candidates for a spontaneous breathing trial (SBT).25 AnSBT may be conducted by having the patient breathe via a“T-piece,” in which the ventilator is disconnected and thepatient breathes through the endotracheal tube connected to a

humidified oxygen supply. An alternative SBT is to use lowlevel PSV (ie 5 cm H2O with 5 cm H2O of PEEP) to over-come the resistance of the endotracheal tube. An SBT isconsidered a failure if the patient has deteriorating arterialblood gas levels, excessive tachypnea or work of breathing,arrhythmias, hypertension or hypotension, diaphoresis, oranxiety. A patient who is comfortable after 30–120 minutesof an SBT may be evaluated for extubation.

ConclusionInvasive mechanical ventilation is a lifesaving interven-

tion for many patients with respiratory failure. Careful atten-tion to ventilator settings and thoughtful adjustments of con-trollable parameters help to provide competent critical care.The ventilator can also be used as a diagnostic tool. As withall medical interventions mechanical ventilation can be po-tentially harmful, and it is essential to discontinue mechanicalventilation as soon as safely possible.

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Fig. 8 The inspiratory hold maneuver. Under conditions ofconstant flow (commonly 60 liters per minute) airway openingpressure increases from PEEP to peak inspiratory pressure(PIP). Flow is then stopped temporarily (without allowing thepatient to exhale) thus eliminating airway resistive pressure.Airway opening pressure drops from PIP to plateau pressure(Pplat). Then the patient is allowed to exhale to set PEEP. Thegradient between PIP and Pplat allows for calculation of airwayresistance; Pplat helps gauge the degree of lung inflation andallows for calculation of the static compliance of the respiratorysystem (see text).

Fig. 9 Approach to a high peak pressure alarm. Abbreviations:PIP, peak inspiratory pressure; Raw, airway resistance; Cstrs, staticcompliance of the respiratory system; ETT, endotracheal tube.

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15. Tobin MJ. Mechanical ventilation. N Engl J Med 1994;330:1056–1061.

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19. Ventilation with lower tidal volumes as compared with traditional tidalvolumes for acute lung injury and the acute respiratory distress syn-drome. The Acute Respiratory Distress Syndrome Network. N EnglJ Med 2000;342:1301–1308.

20. Corbridge TC, Hall JB. The assessment and management of adults withstatus asthmaticus. Am J Respir Crit Care Med 1995;151:1296–1316.

21. Smith TC, Marini JJ. Impact of PEEP on lung mechanics and work ofbreathing in severe airflow obstruction. J Appl Physiol 1989;65:1488–1499.

22. Tuxen DV. Permissive hypercapnic ventilation. Am J Respir Crit CareMed 1994;150:870–874.

23. Tablan OC, Anderson LJ, Arden NH, et al. Guideline for prevention ofnosocomial pneumonia. The Hospital Infection Control Practices Advi-sory Committee, Centers for Disease Control and Prevention. Am JInfect Control 1994;22:247–292.

24. Esteban A, Frutos F, Tobin MJ, et al. A comparison of four methods ofweaning patients from mechanical ventilation. Spanish Lung FailureCollaborative Group. N Engl J Med 1995;332:345–50.

25. Esteban A, Alia I, Tobin MJ, et al. Effect of spontaneous breathing trialduration on outcome of attempts to discontinue mechanical ventilation.Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med1999;159:51–82.

Please see Dr. Muthiah Muthiah and Dr. MuhammadZaman’s editorial on page 1196 of this issue.

“Our own physical body possesses a wisdom which wewho inhabit the body lack. We give it orders which makeno sense.”

—Henry Miller

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