# Control variables: volume and pressure

Control variables in mechanical ventilation are independent parameters which are targeted by the ventilator mechanism, and upon which all other variables are dependent. Along with phase variables, these are among the most important characteristics of a mode of ventilation. In terms of exam relevance, CICM have never asked about this topic directly, perhaps because it is so foundational that all trainees are assumed to have an intuitive grasp of it.

In short:

• The control variable is the parameter which the variable which the ventilator uses as the feedback signal for controlling inspiration
• Pressure flow and volume are all possible control variables, but conventionally only pressure and volume are used.
• The ventilator can only control one variable at a time, but the control variable can change during mechanical ventilation, and even in the course of a single breath.
• Using pressure as the control variable limits the risk of barotrauma and can improve oxygenation (with a square pressure waveform)
• Using volume as the control variable Promotes a stable minute volume, and therefore a stable PaCO2 level
• In either case, the control variable is chosen on the basis of the most clinically important parameter (oxygenation or ventilation)

## Definition of the “control” variable

The word "control" here implies that the person setting the ventilator is most interested in that specific variable, and wants to control that variable exclusively (i.e. without letting the respiratory system make any decisions about it). Pilbeams’ Mechanical Ventilation defines the control variable as “the primary variable the ventilator adjusts to achieve inspiration”. A better way to define it practically is probably the way it is done by Garnero et al (2013):

“the variable which the ventilator uses as feedback signal for controlling inspiration”

This definition has a certain pragmatic appeal. Consider that the ventilator is usually a flow and pressure regulator. The flow and pressure are measured continuously, at millisecond increments. The valves which control this pressure are constantly receiving feedback from the sensors, and in this fashion, the desired variable (pressure or volume) can be achieved and maintained as prescribed.

From a scientific and theoretical standpoint, the most accurate definition is probably the one offered in the  Chatburn chapter from Tobins (3rd ed), which defines the control variable in terms of the equation of motion:

Thus, if one of these variables is pre-determined, it becomes the independent variable in the equation, making all the other variables dependent upon it. Volume and pressure are the only variables which can be pre-determined in this way.  Flow cannot be a control variable because flow is volume over time, and thus when volume is controlled, flow is controlled indirectly.

Extending the metaphor for control brings with it the question, why would one choose one specific control variable over another? Under which circumstances would one want to ventilate the patient with a pressure controlled mode, instead of volume, and vice versa? This is actually a fundamentally important question which often determines the choice of ventilator mode. Modes of ventilation are usually defined primarily by how they handle the control variable.

In brief, the main differences between these control variables are seen in the following domains:

• Reliability of minute volume achieved
• Mean airway pressure achieved
• Recruitment achieved
• Patient comfort and synchrony

It is important to make sure one is clear about the separate discussion of pressure as the control variable from the discussion of the pressure control mode of ventilation (usually abbreviated as PCV) which also has several other characteristics. PCV tends to be created with a square pressure waveform in mind, which has several advantages.  For example, the mean airway pressure is higher, the inspiratory flow rate is higher, and the risk of barotrauma due to inadvertent overdistension is also higher. However, it also can be challenging to achieve the desired minute volume, particularly if the respiratory system characteristics change erratically. In any case, all of these are actually advantages and disadvantages of PCV, not of the pressure control variable. As such, advantages and disadvantages of each mode of ventilation will be discussed elsewhere. Here it will suffice to say that controlling the pressure variable is beneficial because it maintains a stable pressure in the face of fluctuating respiratory performance,  which prevents lung injury from excess pressure. Similarly, using volume as the control variable gives one a more stable minute volume, which keeps the PaCO2 at the desired level, but which may play havoc with respiratory system pressures.

## References

Chatburn, Robert L. "Classification of mechanical ventilators and modes of ventilation." Principles and practice of mechanical ventilation. 3rd ed. New York: McGraw-Hill (2012).

Chatburn, Robert L. "Computer control of mechanical ventilation." Respiratory care 49.5 (2004): 507-517.

HILL, J. DONALD, et al. "Correct use of respirator on cardiac patient after operation." Archives of Surgery 91.5 (1965): 775-778.

Rabec, Claudio, et al. "Ventilatory Modes. What's in a Name? The authors respond." Respiratory care 57.12 (2012): 2138-2150.

Campbell, Robert S., and Bradley R. Davis. "Pressure-controlled versus volume-controlled ventilation: does it matter?." Respiratory care 47.4 (2002): 416-24.

Rittayamai, Nuttapol, et al. "Pressure-controlled vs volume-controlled ventilation in acute respiratory failure: a physiology-based narrative and systematic review." Chest 148.2 (2015): 340-355.

Chatburn, Robert L., Teresa A. Volsko, and Mohamad El-Khatib. "The effect of airway leak on tidal volume during pressure-or flow-controlled ventilation of the neonate: A model study." Respiratory care 41.8 (1996): 728-735.

Chatburn, Robert L., F. E. Khatib, and Paul G. Smith. "Respiratory system behavior during mechanical inflation with constant inspiratory pressure and flow." Respiratory care 39.10 (1994): 979-986.

Garnero, A. J., et al. "Pressure versus volume controlled modes in invasive mechanical ventilation." Medicina Intensiva (English Edition) 37.4 (2013): 292-298.