Mechanical Ventilation Modes and Clinical Applications

Primary Ventilation Modes

The selection of ventilation mode should be guided by the underlying pathophysiology, disease severity, and patient respiratory drive, with no single mode demonstrating superiority across all conditions 1, 2
Volume-Controlled Ventilation (VCV) delivers a preset tidal volume with resulting pressure determined by lung compliance and airway resistance, and is primarily used in patients requiring guaranteed minute ventilation, particularly those with obesity 3, 4
The American Thorax Society recommends a target tidal volume of 6-8 ml/kg ideal body weight to minimize ventilator-induced lung injury in VCV 3, 5
Pressure-Controlled Ventilation (PCV) delivers a preset inspiratory pressure with resulting tidal volume dependent on lung compliance and resistance, and is primarily used in patients at risk for barotrauma or with poor lung compliance 3, 6
Assist-Control Ventilation (ACV) guarantees a minimum respiratory rate while allowing patient-triggered breaths that receive full ventilator support, and is primarily used in patients with variable respiratory drive, particularly for prolonged ventilation and nighttime use 3, 5
The Intensive Care Medicine society recommends adjusting expiratory time carefully in ACV to prevent poor tolerance 3, 7

Proportional Assist Ventilation (PAV) delivers pressure proportional to patient effort based on respiratory mechanics, and is primarily used to improve patient-ventilator synchrony and potentially sleep quality 7
Neurally Adjusted Ventilatory Assist (NAVA) delivers pressure proportional to diaphragmatic electrical activity, and is primarily used to optimize patient-ventilator interaction in patients with significant asynchrony 7
High-Frequency Oscillatory Ventilation (HFOV) may be considered when conventional ventilation fails using open lung strategy, but should not be used in obstructive airway disease due to dynamic hyperinflation risk 1, 2

Continuous Positive Airway Pressure (CPAP) increases mean airway pressure, recruits collapsed alveoli, and offsets intrinsic PEEP, and is primarily used to correct hypoxemia in mild-to-moderate respiratory failure 2, 3
Non-Invasive Ventilation (NIV) can be considered before intubation in obstructive airway disease, restrictive disease, mild-to-moderate PARDS, or cardiorespiratory failure, but should not delay intubation when failing 1, 2
High-Flow Nasal Cannula (HFNC) may reduce work of breathing but has no outcome data showing superiority over other interventions 2

The Intensive Care Medicine society recommends maintaining plateau pressure ≤28 cmH2O in most conditions, and ≤32 cmH2O if chest wall elastance is increased 1
The American Thorax Society recommends keeping SpO2 ≤97% in the general ICU, and 92-97% in PARDS with PEEP <10 cmH2O 8, 9
The Intensive Care Medicine society recommends targeting pH >7.20 in most conditions, and normal pH in pulmonary hypertension 8, 9

The Intensive Care Medicine society recommends assessing respiratory drive, evaluating disease severity, and considering pathophysiology when selecting a ventilation mode 1, 2, 3
The American Thorax Society recommends using ACV at night to prevent central apneas in patients with prolonged ventilation 5
The Intensive Care Medicine society recommends using PSV with carefully adjusted support to prevent hyperventilation during weaning 7, 5

The Intensive Care Medicine society recommends starting weaning as soon as possible, and performing daily extubation readiness testing 8, 9
The American Thorax Society recommends considering NIV for neuromuscular patients post-extubation 8, 9
The Intensive Care Medicine society recommends using corticosteroids in patients at increased risk for post-extubation stridor 8, 9