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Adult Invasive Mechanical Ventilation

A mechanics-first clinical guide to adult invasive ventilation, from pressure interpretation and mode structure to patient–ventilator interaction and troubleshooting.

On this page
  1. Scope and terminology
  2. Respiratory pressures and mechanics
  3. Structure of a ventilator mode
  4. Continuous mandatory ventilation
  5. Intermittent mandatory ventilation
  6. Spontaneous ventilatory support
  7. Adaptive and hybrid modes
  8. Specialized and device-dependent modes
  9. Manufacturer crosswalk
  10. Physiology-guided clinical application
  11. Waveforms and patient–ventilator interaction
  12. Troubleshooting

Scope and terminology

This guide addresses positive-pressure invasive ventilation through an artificial airway in adults receiving intensive care. Paediatric and neonatal ventilation, non-invasive and home ventilation, and anaesthesia-workstation operation are outside its scope.

Mode labels describe control logic, not an indication or a complete prescription. Select targets and alarms for the patient, disease, monitoring capability, and device; this guide does not provide universal starting settings or claim that one control variable is superior.

Respiratory pressures and mechanics

With respiratory-system inertance neglected, the linear single-compartment equation of motion during inspiration is Pvent(t) + Pmus(t) = PEEPtotal + V(t)/Crs + Rinsp × V̇insp(t). In this applied-pressure convention, inspiratory Pmus is positive: it is the pressure contribution applied by the inspiratory muscles, not the signed pleural-pressure change; Pmus = 0 during passive ventilation.

Pressure quantities Pvent, Pmus, Paw, Palv, Ppl, PEEPset, PEEPtotal, Ppeak, Pplat, ΔP, Pmean, and PL are expressed in cm H₂O. V(t) is the volume change above the end-expiratory reference at PEEPtotal, where V(0) = 0; VT is the end-inspiratory volume change, and both use L or mL consistently. V̇insp is in L/s; Crs is in L/cm H₂O or mL/cm H₂O; Rinsp and Rexp are in cm H₂O·s/L; τinsp and τexp are in seconds.

Static partitioning requires a passive patient, no relevant leak, stable volume, and zero flow during a valid end-inspiratory occlusion or end-expiratory occlusion. Known constant inspiratory flow is required for the simple Rinsp equation. Coughing, active inspiration or expiration, leaks, and unstable flow invalidate or distort these estimates.

During assisted ventilation, patient effort and ventilator pressure act together. Inspiratory muscle pressure can lower measured airway pressure while increasing flow, volume, or transpulmonary distending pressure; continued effort during an occlusion can make plateau pressure or total PEEP misleading.

Peak inspiratory pressure (Ppeak)

Definition and relation
The maximum airway pressure during inspiration. With passive constant-flow inflation, it contains set and intrinsic PEEP plus elastic and resistive pressure.
Valid measurement and limits
Interpret with the simultaneous flow waveform and Pplat. A change in flow or patient effort changes Ppeak even if respiratory-system mechanics are unchanged.

Plateau pressure (Pplat)

Definition and relation
Airway pressure after pressure equilibrates during zero flow at end inspiration; it approximates respiratory-system elastic pressure plus total PEEP, not lung stress alone.
Valid measurement and limits
Use a valid end-inspiratory occlusion during passive inflation with no leak. Confirm a stable plateau and exclude inspiratory or expiratory muscle activity.

Resistive pressure

Definition and relation
The pressure required to generate flow through the tube, circuit, airways, and flow-dependent tissue resistance; under constant flow it is approximated by Ppeak − Pplat.
Valid measurement and limits
Compare breaths at the same flow and volume. The difference cannot be interpreted as resistance when flow is changing or effort distorts airway pressure.

Elastic pressure

Definition and relation
The pressure above total PEEP required to deliver VT against combined lung and chest-wall elastance; under passive static conditions it is Pplat − PEEPtotal.
Valid measurement and limits
It is a respiratory-system quantity. Chest-wall stiffness and abdominal pressure can raise it without an equivalent rise in lung transpulmonary pressure.

Set, total, and intrinsic PEEP

Definition and relation
Set PEEP is the ventilator baseline; total PEEP is static end-expiratory alveolar pressure; intrinsic PEEP (auto-PEEP) is PEEPtotal − PEEPset.
Valid measurement and limits
Measure total PEEP with a valid end-expiratory occlusion in a passive patient without leak. Expiratory flow that has not returned to zero suggests incomplete emptying but does not quantify regional gas trapping.

Driving pressure (ΔP)

Definition and relation
For passive tidal inflation, ΔP = Pplat − PEEPtotal = VT/Crs. It represents the tidal elastic pressure of the whole respiratory system.
Valid measurement and limits
Use Pplat and total, not merely set, PEEP from valid static measurements. Comparisons are unreliable when VT, effort, chest-wall mechanics, or occlusion quality changes.

Mean airway pressure (Pmean)

Definition and relation
The time-average of airway pressure over the complete respiratory cycle: Pmean = (1/T)∫₀ᵀ Paw(t)dt. Here T is the duration of the complete respiratory cycle in seconds.
Valid measurement and limits
It depends on the pressure waveform, PEEP, inspiratory duration, frequency, flow pattern, and spontaneous effort. It is not interchangeable with Pplat or ΔP.

Transpulmonary pressure (PL)

Definition and relation
PL = Palv − Ppl: alveolar minus pleural pressure. It separates lung distension from chest-wall load; airway Pplat alone cannot do this.
Valid measurement and limits
Pleural pressure is commonly estimated with calibrated oesophageal pressure, with position and regional limitations. Specify whether an absolute static value or a tidal swing is used; no universal PL target is inferred here.

Static respiratory-system compliance

Equation, units, and conditions
Crs = VT / (Pplat − PEEPtotal), expressed in mL/cm H₂O or L/cm H₂O, using passive zero-flow measurements without leak.
Interpretation
A change can arise from lung volume, recruitment or overdistension, oedema, pleural or abdominal factors, chest-wall mechanics, position, or invalid measurement.

Inspiratory respiratory-system resistance (Rinsp)

Equation, units, and conditions
Rinsp = (Ppeak − Pplat) / V̇insp, expressed in cm H₂O·s/L, using passive volume-controlled inflation with known constant inspiratory flow.
Interpretation
A rise prompts assessment of the artificial airway, secretions, bronchospasm, circuit resistance, and flow. Compare only under matched flow conditions.

Inspiratory and expiratory time constants

Equation, units, and conditions
τinsp = Rinsp × Crs and τexp = Rexp × Crs, both expressed in seconds. In a passive linear single-compartment model, one τ corresponds to about 63% of the applicable volume change after a pressure step.
Interpretation
Rexp is not assumed to equal Rinsp. τexp describes passive expiration with Pmus = 0 and no leak; it reflects expiratory airway and ventilator expiratory-circuit resistance, whereas τinsp uses the separately measured Rinsp. Heterogeneous lungs contain multiple time constants, so either global value is an approximation.

Structure of a ventilator mode

Describe a mode by its control variable, breath sequence, and targeting scheme, then define how each breath starts, is limited, and ends. A commercial label is not enough to establish these properties.

Control variable

Question
Is pressure or volume/flow constrained during inspiration?
Clinical meaning
The unconstrained variable changes with resistance, compliance, effort, leak, and the chosen waveform.

Breath sequence

Question
Are breaths mandatory, spontaneous, or both?
Clinical meaning
CMV contains mandatory breaths; IMV combines mandatory and spontaneous breaths; CSV contains spontaneous breaths. Patient triggering does not by itself make a breath spontaneous.

Targeting scheme

Question
Which targets are fixed, adapted between breaths, proportional to a signal, or governed by a higher controller?
Clinical meaning
The targeting scheme explains which variables the algorithm may change and which measured signal drives that change.

Trigger

Question
What starts inspiration?
Clinical meaning
A time signal or a validated patient signal such as pressure, flow, or diaphragm electrical activity can initiate a breath.

Limit

Question
Which variable is constrained during inspiration without ending it?
Clinical meaning
Pressure, flow, or volume limits shape delivery and may activate protective boundaries; a limit is not necessarily the cycling criterion.

Cycle

Question
What ends inspiration?
Clinical meaning
Time, flow, volume, pressure, or an algorithm can terminate inspiration and thereby change synchrony and expiratory time.

Continuous mandatory ventilation

VC-CMV

Every breath is mandatory; the selected volume and flow pattern are the primary constrained variables, including for patient-triggered breaths.

Airway pressure changes with resistance, compliance, total PEEP, flow, and respiratory effort.

Patient inspiration can lower the pressure waveform despite substantial muscle pressure; a low displayed pressure does not prove low transpulmonary distension.

Review expired volume, Ppeak, a valid Pplat and total PEEP when measurable, flow and pressure waveforms, gas exchange, effort, and haemodynamics after changes.

PC-CMV

Every breath is mandatory; inspiratory pressure and timing are constrained, while flow is variable and commonly decelerating.

VT changes with the pressure gradient, respiratory-system mechanics, available inspiratory time, leak, and respiratory effort.

Patient inspiration can increase flow and VT without raising the set airway pressure, so the pressure trace alone can underestimate total inspiratory load.

Review expired VT and minute ventilation, flow decay, total PEEP, effort, gas exchange, and haemodynamics whenever mechanics or spontaneous activity changes.

Intermittent mandatory ventilation

SIMV combines mandatory breaths with spontaneous breaths between them. Evaluate each breath type separately; SIMV is not inherently a liberation strategy or a guarantee of appropriate work of breathing.

VC-SIMV

Mandatory breaths use volume control. Spontaneous breaths depend on the patient and any separate pressure support; assess the mandatory flow/volume pattern and the spontaneous trigger, cycling, effort, and contribution to total ventilation.

PC-SIMV

Mandatory breaths use pressure control. Track their delivered VT separately from supported or unsupported spontaneous breaths, and check whether changing effort alters total ventilation or creates over-assistance.

Spontaneous ventilatory support

In spontaneous support modes, the patient initiates inspiration, while breath duration is usually determined by inspiratory flow. Effective ventilation depends on respiratory drive, respiratory-muscle capacity, trigger settings, pressure rise time, cycling to expiration, respiratory mechanics, leak, and the availability of backup ventilation.

Pressure support ventilation (PSV)

Each patient-triggered breath receives a set level of pressure support and usually cycles to expiration when inspiratory flow falls to a predefined threshold. Match trigger sensitivity, rise time, and cycling criteria to patient effort and respiratory mechanics. Monitor for ineffective efforts, excessive VT, premature cycling, and delayed cycling.

Invasive CPAP

CPAP maintains continuous positive airway pressure without additional inspiratory assistance. It requires adequate spontaneous ventilation, reliable apnoea detection, and appropriately configured backup ventilation.

Balance of support

Insufficient support increases respiratory effort and inspiratory-flow demand. Excessive support may reduce respiratory drive, increase VT, cause delayed cycling, and mask respiratory-muscle weakness. Assess patient effort, ventilation, comfort, and patient–ventilator synchrony together.

Adaptive and hybrid modes

In these modes, the ventilator automatically adjusts selected ventilation parameters using measured feedback. Interpret them according to the breath type, feedback signal, selected targets, active limits, and the algorithm’s response to changes in respiratory effort and lung mechanics.

PRVC-type modes with tidal-volume targeting

Mandatory breaths are pressure controlled, while the ventilator adjusts inspiratory pressure between breaths to approach the set VT. The target volume may not be achieved when pressure limits are reached or when leaks, respiratory mechanics, or patient effort change.

AutoFlow

AutoFlow adapts inspiratory pressure in modes with a set tidal volume and delivers inspiration with a decelerating flow pattern. Assess actual VT, airway pressure, flow, and patient–ventilator interaction. Implementation and available settings depend on the ventilator model.

Volume-targeted pressure support

During spontaneous breaths, the ventilator adjusts pressure support between breaths to approach the set VT. Stronger patient effort may reduce ventilator pressure, while weaker effort may increase it; therefore, VT should be interpreted together with patient effort.

Adaptive support ventilation: ASV

ASV automatically selects a combination of respiratory rate, VT, and pressure support based on the set minute ventilation, measured respiratory mechanics, and spontaneous patient activity. Assess the resulting breath sequence, VT, rate, pressure, patient effort, and active safety limits.

INTELLiVENT-ASV

INTELLiVENT-ASV extends ASV with automated control of ventilation and oxygenation using the selected clinical profile and measured signals. Confirm the selected targets, signal quality, controller status, active limits, and backup behaviour.

Specialized and device-dependent modes

The availability and implementation of these modes depend on the ventilator model and its software configuration. Identify each mode by its control principle, patient signal, breath sequence, and backup logic rather than by its name alone.

Time-cycled two-level pressure modes: APRV and BiLevel-type modes

The ventilator alternates between upper and lower pressure levels at predefined time intervals, while spontaneous breathing may be permitted at both levels. Assess the pressure levels, duration of each phase, release flow and volume, support of spontaneous breaths, total minute ventilation, gas exchange, and haemodynamics. Modes with similar names may differ in their algorithms and available settings.

Minimum minute ventilation: MMV

MMV automatically increases the mandatory component of ventilatory support when measured minute ventilation falls below a predefined minimum and reduces it as adequate spontaneous ventilation returns. Confirm how the ventilator calculates minute ventilation, counts spontaneous breaths, and limits the additional support.

Proportional ventilatory assistance: PAV+

PAV+ adjusts inspiratory assistance in proportion to estimated patient effort, using measured flow and volume together with estimated resistive and elastic loads of the respiratory system. Confirm that measurements are reliable, significant leaks are absent, and artificial-airway data are correct. Availability, operating limits, and backup behaviour depend on the specific ventilator.

Neurally adjusted ventilatory assist: NAVA

NAVA uses the electrical activity of the diaphragm—EAdi—measured through a dedicated oesophageal catheter to trigger and cycle breaths and to scale assistance proportionally. Confirm catheter position and signal quality. Continue to assess airway pressure, VT, respiratory rate, gas exchange, and patient effort.

Automatic tube compensation: ATC

ATC estimates the pressure drop across an endotracheal or tracheostomy tube using its type, internal diameter, and measured flow, and adds pressure to partially offset this resistance. It does not compensate for resistance caused by accumulated secretions, partial obstruction or kinking of the tube, bronchospasm, or the breathing circuit.

Manufacturer crosswalk

This table maps only behavior verified in the cited documents. Exact revisions are listed in the source metadata; a dash means that the current evidence set does not support a crosswalk entry, not that the function is unavailable.

Adaptive mandatory volume targeting

Dräger
VC-CMV + AutoFlow
Hamilton
APVcmv / (S)CMV+
Important implementation distinction
Dräger exposes AutoFlow as an additional setting in its volume-controlled mode family; for CMV + AutoFlow, breath taxonomy classifies pressure control with adaptive targeting (PC-CMVa). Hamilton APVcmv also targets mandatory volume with adaptive pressure control, but the names are not interchangeable.

Adaptive spontaneous volume targeting

Dräger
—
Hamilton
VS
Important implementation distinction
VS applies a volume target to spontaneous breaths; it is distinct from adaptive mandatory ventilation.

Adaptive pattern and gas-exchange controllers

Dräger
—
Hamilton
ASV / INTELLiVENT-ASV
Important implementation distinction
ASV selects the ventilatory pattern from physiological input; INTELLiVENT-ASV adds clinician-bounded carbon-dioxide elimination and oxygenation controllers.

Time-cycled two-level pressure

Dräger
PC-APRV
Hamilton
DuoPAP / APRV
Important implementation distinction
Spontaneous-breath support, transition timing, and release behavior remain implementation-specific.

Minimum minute ventilation

Dräger
VC-MMV
Hamilton
—
Important implementation distinction
The cited implementation combines measured minute volume, volume-controlled mandatory breaths, and spontaneous activity; it is not a generic liberation protocol.

Artificial-airway resistance compensation

Dräger
ATC
Hamilton
TRC
Important implementation distinction
Both are device estimates based on tube and flow information; their settings and calculations are platform-specific.

Physiology-guided clinical application

Select the mode according to the main physiological problem and define in advance how the response will be assessed. A mode is appropriate only when the ventilation it actually delivers remains consistent with the patient-specific strategy as respiratory mechanics and effort change.

ARDS and acute hypoxaemia

Use a mode that reliably delivers the individualized lung-protective strategy and allows assessment of expired VT, reliably measured Pplat and total PEEP, ΔP, gas exchange, respiratory effort, and haemodynamics. The mode name itself does not provide lung protection.

Obstructive disease and dynamic hyperinflation

Provide sufficient expiratory time and confirm that expiratory flow returns to zero. Distinguish set, total, and intrinsic PEEP; assess expiratory flow limitation, trigger workload, and haemodynamics. Changing the mode without adjusting expiratory time or minute ventilation will not correct dynamic hyperinflation.

Marked respiratory effort or dyssynchrony

Identify pain, anxiety, fever, acidosis, hypoxaemia, and other causes of increased respiratory drive. Assess work of breathing, respiratory mechanics, and whether support matches patient demand. Strong inspiratory effort may reduce airway pressure while increasing transpulmonary pressure. Adjust triggering, inspiratory flow, rise time, cycling to expiration, and support only after identifying the mechanism, then reassess.

Neurological impairment

Assess gas exchange, airway protection, and the ability to initiate and sustain ventilation separately. Level of consciousness, sedation, seizures, respiratory drive, cough, secretion burden, intracranial pressure, and cerebral perfusion determine the need for reliable mandatory or backup ventilation and readiness for extubation.

Liberation from mechanical ventilation

When readiness criteria are met, perform a structured assessment and a spontaneous breathing trial. During assisted ventilation, ensure that low support is not associated with excessive work of breathing and that high support is not suppressing spontaneous activity. Before extubation, also assess airway protection, cough, secretion burden, and the risk of extubation failure.

Waveforms and patient–ventilator interaction

Interpret pressure, flow, and volume together with the patient’s clinical condition. Confirm the likely cause before changing settings and reassess the response afterward.

Ineffective inspiratory effort

Pattern
A pressure dip or expiratory-flow deflection does not trigger an assisted breath.
Likely causes
Intrinsic PEEP, insensitive trigger, weak effort, over-assistance, sedation, or leak.
What to check
Correlate patient effort with the waveforms; assess total PEEP, trigger function, leak, and respiratory drive.
Possible adjustment
Trigger sensitivity, expiratory time, external PEEP, support level, and reversible causes of weak effort.
After adjustment
Reliable triggering without auto-triggering, fewer ineffective efforts, and stable VT and ventilation.

Double triggering and breath stacking

Pattern
Two breaths occur with little or no expiration between them, increasing total VT.
Likely causes
Prolonged neural inspiration, high effort, inadequate flow, premature cycling, or reverse triggering.
What to check
Assess stacked VT, inspiratory duration, flow demand, effort, pain, acidosis, and sedation.
Possible adjustment
Inspiratory flow, pressure rise, inspiratory time or cycling criterion, and support level.
After adjustment
Separated breaths, acceptable VT and pressures, lower effort, and preserved gas exchange.

Insufficient inspiratory flow

Pattern
During volume control, the pressure curve becomes concave and inspiratory effort persists.
Likely causes
Insufficient flow, pressure rise, or support; pain, fever, anxiety, acidosis, or high ventilatory demand.
What to check
Compare delivered flow with patient demand and identify clinical causes of increased respiratory drive.
Possible adjustment
Flow pattern and peak flow, pressure rise, inspiratory time, support, and treatment of the cause.
After adjustment
Lower effort and distress, smoother pressure contour, acceptable VT and pressures, and adequate expiratory time.

Premature cycling

Pattern
Ventilator inspiration ends before patient effort, often causing immediate retriggering.
Likely causes
High flow-cycle threshold, short inspiratory time, or insufficient flow or support.
What to check
Compare the end of ventilator inspiration with patient effort; check leak, cycling criterion, inspiratory time, and VT.
Possible adjustment
Cycling criterion, inspiratory time, inspiratory flow, and support level.
After adjustment
Better breath matching without excessive VT, double triggering, or shortened expiration.

Delayed cycling

Pattern
Inspiratory flow continues after patient effort ends, with active expiration or a late pressure rise.
Likely causes
Low flow-cycle threshold, excessive support, leak, long inspiratory time, or obstruction.
What to check
Assess expiratory effort, leak, flow decay, respiratory mechanics, and support level.
Possible adjustment
Cycling criterion, inspiratory time, leak correction, pressure support, and pressure-rise setting.
After adjustment
Timely expiration, less expiratory effort, and adequate VT and ventilation.

Incomplete expiration

Pattern
Expiratory flow does not return to zero before the next inspiration.
Likely causes
Obstruction, long time constant, high minute ventilation, short expiratory time, or active expiration.
What to check
Assess resistance, ventilatory demand, expiratory time, haemodynamics, and total PEEP.
Possible adjustment
Increase expiratory time; adjust rate, inspiratory flow or time, support, and treatment of obstruction.
After adjustment
Improved lung emptying, lower total PEEP, better triggering, gas exchange, and haemodynamics.

Changes in Ppeak and Pplat

Pattern
Ppeak rises with stable Pplat, or both pressures rise together.
Likely causes
An isolated Ppeak rise suggests increased resistance; a Pplat rise suggests reduced compliance or increased total PEEP.
What to check
Repeat passive measurements and inspect the tube, circuit, airways, chest wall, lung volume, and patient position.
Possible adjustment
Treat airway or circuit obstruction; adjust VT, PEEP, position, and treatment of the underlying disease.
After adjustment
Repeat Ppeak, Pplat, total PEEP, Crs, and Rinsp and assess ventilation and haemodynamics.

Troubleshooting

Assess the patient, airway, circuit, and ventilator in parallel. If ventilation is ineffective or the patient is unstable, call for help and provide an immediately available alternative means of ventilation under the local airway-emergency pathway while the cause is sought.

Sudden instability or absent ventilation

Confirm chest movement, oxygenation, airway position and patency, circuit continuity, gas supply, and exhalation. Separate disconnection or leak from tube/circuit obstruction, pneumothorax, severe bronchospasm, and loss of respiratory activity.

High airway pressure

Use valid Ppeak–Pplat–PEEPtotal partitioning when the patient can be passive. Treat tube, secretion, bronchospasm, or circuit resistance when the rise is resistive; investigate lung/chest-wall volume, pleural or abdominal causes, position, and total PEEP when the elastic component rises.

Low or changing expired volume

Check leak and disconnection first, then pressure limits, mechanics, inspiratory time, effort, cycling, and the active targeting scheme. In pressure control, falling VT may reveal worsening mechanics; in adaptive modes, changing pressure may be the controller response rather than the cause.

Worsening oxygenation

Verify oxygen delivery and airway/circuit integrity, then assess recruitment loss, secretion or atelectasis, oedema, pneumothorax, haemodynamics, position, and ventilation–perfusion causes. Reassess the full oxygenation strategy and patient response, not the mode label alone.

Apnea or loss of patient triggering

Immediately restore effective ventilation and evaluate central respiratory activity, sedation, neurological change, fatigue, over-assistance, intrinsic PEEP, trigger signal, and circuit continuity. Confirm that the active mandatory backup and alarms match the patient’s current risk.

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    Open source

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    Open source

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