Pressure Control Ventilation: Clinical Indications and Comparative Advantages

Primary Indication: Assisted Breathing and Patient Comfort

Pressure control ventilation (PCV) is preferred during assisted or spontaneous breathing phases when patient comfort and synchrony are priorities, while volume control ventilation (VCV) should be used during passive ventilation in early ARDS to facilitate measurement of respiratory mechanics and driving pressure 1, 2
PCV offers superior respiratory comfort during assisted breathing because it does not limit inspiratory flow, allowing the ventilator to match variable patient demand 1, 2

During the early passive ventilation phase of ARDS, VCV is recommended because it facilitates measurement of respiratory mechanics and driving pressure, which are critical for lung-protective ventilation 1, 2
VCV allows automatic collection of plateau pressure and driving pressure during inspiratory pause, essential for titrating PEEP and assessing lung stress 3
For the same tidal volume, there is no outcome advantage between PCV and VCV in terms of stress and strain generated in the lung 1, 2
VCV guarantees fixed tidal volume delivery, crucial when implementing the 6 mL/kg predicted body weight lung-protective strategy 4

Either PCV or VCV can be used in patients with obesity undergoing surgery, with the choice based on procedural factors 5
PCV may promote more homogeneous ventilation and improve oxygenation in obese patients 5
VCV allows better tidal volume control during procedures that intermittently affect chest wall compliance 5

VCV is essential when reducing tidal volume from 6 mL/kg to 4 mL/kg predicted body weight for plateau pressures >30 cm H₂O 4
VCV ensures consistent minute ventilation when permissive hypercapnia is employed 4
The overdistension-collapse method for PEEP titration requires VCV with inspiratory pause >0.5 seconds to measure driving pressure 3
VCV should be considered when ensuring consistent alveolar ventilation is crucial and patients fail on pressure support 6

Both modes can achieve lung protection when tidal volume, plateau pressure, and driving pressure are appropriately managed 1, 2
Begin with VCV during early passive ARDS ventilation, then transition to PCV when weaning sedation and allowing spontaneous breathing efforts 1, 2
During VCV: Monitor plateau pressure, driving pressure, and tidal volume delivery 3, 4
Driving pressure (plateau pressure minus PEEP) predicts outcomes regardless of mode and should be kept <15 cm H₂O 4

The American Thoracic Society recommends transitioning from volume control (VC) to pressure control (PC) ventilation when switching from controlled to assisted invasive mechanical ventilation as patient recovery allows 7
In patients with obesity hypoventilation syndrome (OHS) requiring high inflation pressures, volume-assured modes are more effective, according to the European Respiratory Society 7
The transition to PC ventilation should occur when patient comfort and synchrony become priorities, such as during assisted or spontaneous breathing phases, as suggested by the American College of Chest Physicians 7

For OHS patients, the American Academy of Sleep Medicine recommends considering volume-assured modes for high pressure requirements 7

The European Respiratory Society warns that PC bi-level systems have significant rebreathing potential that can worsen hypercapnia, especially in tachypneic patients with respiratory rates >20/min 8
The American Thoracic Society advises monitoring arterial blood gases (ABGs) closely after transitioning to PC for unexpected hypercapnia from rebreathing, especially if respiratory rate increases 8
The Society of Critical Care Medicine recommends ensuring exhalation ports are functioning properly to prevent occlusion by sputum, which can exacerbate hypercapnia through rebreathing 9

Volume control better ensures alveolar ventilation when compliance or airway resistance changes acutely, as stated by the American College of Chest Physicians 8
VC is essential when reducing tidal volume from 6 to 4 mL/kg predicted body weight for plateau pressures >30 cmH₂O, according to the European Respiratory Society 9
VC better compensates for air leaks, though tidal volumes must be arbitrarily increased, as suggested by the American Thoracic Society 9