Ventilation Modes in the Cardiovascular Intensive Care Unit (CVICU)

Common Ventilation Modes in CVICU

Assist-control ventilation (ACV) should be used at night over pressure support ventilation (PSV) in CVICU patients to improve sleep quality, reduce central apneas, and optimize patient-ventilator synchrony, as recommended by the American Thoracic Society 1, 2
Assist-Control Ventilation (ACV) delivers a preset tidal volume or pressure when triggered by patient effort or time, providing backup ventilation and improving sleep efficiency by preventing central apneas due to its backup rate, according to the Society of Critical Care Medicine 3, 4
Pressure Support Ventilation (PSV) augments spontaneous breathing with preset pressure support, but may cause central apneas during sleep if set too high, leading to hyperventilation and hypocapnia, particularly problematic in cardiac patients, as noted by the European Society of Intensive Care Medicine 3, 4
Proportional Assist Ventilation (PAV) delivers pressure proportional to patient effort based on respiratory mechanics, improving patient-ventilator synchrony and potentially enhancing sleep quality, as recommended by the American College of Chest Physicians 3, 5
Neurally Adjusted Ventilatory Assist (NAVA) uses diaphragmatic electrical activity to proportionally assist breathing, minimizing asynchrony but requires specialized equipment, according to the Society of Critical Care Medicine 3, 5

ACV is superior to PSV for sleep quality, preventing central apneas during sleep, improving total sleep time and reducing sleep fragmentation compared to PSV, as recommended by the American Academy of Sleep Medicine 1, 4
PSV can worsen sleep, with 54% of patients developing central apneas during PSV, leading to arousals and sleep fragmentation, particularly problematic in heart failure patients, as noted by the Heart Failure Society of America 3, 4
Adding dead space to PSV can reduce central apneas if PSV must be used, according to the European Society of Intensive Care Medicine 3
Proportional modes (PAV, NAVA) improve patient-ventilator interaction by proportionally unloading patient effort, reducing asynchrony which is associated with prolonged ventilation and increased mortality, as recommended by the Society of Critical Care Medicine 3, 5
Patient-ventilator asynchrony is associated with prolonged mechanical ventilation, increased morbidity, mortality, and poorer sleep quality, according to the American Thoracic Society 3

Use ACV at night to improve sleep quality and prevent central apneas, as recommended by the American College of Chest Physicians 1, 2
If using PSV, carefully adjust the level of assistance to prevent hyperventilation and central apneas, particularly in patients with heart failure, according to the Heart Failure Society of America 3, 7
Consider proportional modes (PAV or NAVA) to improve patient-ventilator synchrony and potentially sleep quality, though evidence for sleep improvement is mixed, as noted by the Society of Critical Care Medicine 3, 5
Target tidal volume of 4-8 ml/kg predicted body weight to minimize complications, as recommended by the American Thoracic Society 6
Use PEEP of 4-8 cmH2O to offset intrinsic PEEP and improve triggering, according to the European Society of Intensive Care Medicine 6
Maintain SpO2 between 88-92% to avoid worsening hypercapnia, as recommended by the American College of Chest Physicians 6, 8
Set respiratory rate between 10-14 breaths/min initially, according to the Society of Critical Care Medicine 6
Allow adequate expiratory time (I:E ratio of 1:2 or 1:3) to prevent air trapping, especially important in COPD patients, as noted by the American Thoracic Society 6, 8