Mechanical Ventilation: Pressure-Regulated Volume Control Ventilation (Respiratory Therapy)

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ALERT

Ventilator failure or accidental disconnection can be catastrophic in patients undergoing neuromuscular blockade.

OVERVIEW

Pressure-regulated volume control (PRVC) ventilation combines volume and pressure strategies for invasive mechanical ventilation. PRVC delivers a pressure-controlled, tidal volume (VT)–targeted breath with a decelerating flow waveform pattern that allows spontaneous breathing with or without pressure support (PS). Settings, terminology, and abbreviations may vary by ventilator brand.

PRVC is an advanced ventilation mode that adjusts to the patient’s needs breath by breath, using both volume and pressure.^{undefined#ref1">1} It delivers the lowest pressure and appropriate flow to meet the VT target.^1,2 Patient’s may breathe above the set rate, with all breaths being patient or time-triggered. The ventilator adjusts pressure levels based on the previous breaths to meet the VT target or minute ventilation demand.

Initially, the ventilator delivers pressure starting at 5 cm H₂O below the set upper pressure limit.¹ It automatically adjusts inspiratory pressure based on changes in lung compliance, resistance, and respiratory effort.³ If the pressure limit is reached before the VT target, or if the VT target is exceeded, the ventilator adjusts the pressure up or down for the next breath (Figure 1). As lung compliance decreases, more inspiratory pressure is needed to deliver the VT target. As the patient recovers and compliance increases, the inspiratory pressure decreases while meeting the VT target.

PRVC is used for acute respiratory distress syndrome (ARDS) management, maximizing alveolar recruitment, patient comfort, and synchrony while minimizing barotrauma and volutrauma risks.^1,3 PRVC is a safe and comfortable mode of ventilation for all ages.

SUPPLIES

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EDUCATION

• Give developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, preferred learning style, and overall neurologic and psychosocial state.
• Explain the need for ventilator changes to the patient and family.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Assess the patient for PRVC or equivalent mode and signs of ARDS.
   1. Decreasing partial pressure of arterial oxygen/fraction of inspired oxygen (PaO₂/FIO₂) ratio
   2. Increasing plateau pressure, peak inspiratory pressure (PIP), or mean airway pressure (MAP)
   3. Bilateral lung infiltrates on a chest radiograph
2. Assess the patient’s hemodynamic and cardiorespiratory systems.

Preparation

1. Gather equipment, including a ventilator with PRVC or equivalent mode, circuit, humidification device, filters (if needed), and closed suction device.
2. Before initiating the mechanical ventilator, check the microprocessor or ventilation system. Perform a short self-test as appropriate.
   1. Verify compliance of the ventilator circuit with the humidification device and filters (if needed).
   2. Document the completed ventilation system test. Include pass or fail, date, initials or signature, and credentials.
3. Verify the practitioner’s order for the initiation of mechanical ventilation or mode of ventilation change.

PROCEDURE

1. Clean hands and put on appropriate personal protective equipment (PPE) based on the risk of exposure to body fluids or infection precautions.
2. Verify the correct patient using two identifiers.
3. Explain the procedure and ensure that the patient agrees to treatment.
4. Transition the patient to PRVC or an equivalent mode using the prescribed settings.

   Setting options, terminology, and abbreviations may be brand specific based on trademarked mechanical ventilator specifications.

5. Select the appropriate patient designation (e.g., adult, pediatric, infant).
6. Select and enter the PRVC or equivalent mode depending on the manufacturer’s software.
7. Set the desired minimum respiratory rate.

   The patient may breathe above the set respiratory rate.

8. Set the desired VT target using ideal body weight calculations for lung protective strategy.

   If the VT target is not met, the ventilator responds by adjusting the inspiratory pressure up or down accordingly in small increments in the attempt to meet the VT target for the next breath (Figure 1).

9. Set the desired FIO₂ delivery.
10. Set the desired inspiratory time or inspiratory-to-expiratory (I:E) ratio.
11. Set the desired positive end-expiratory pressure (PEEP) level.
12. Set the desired trigger sensitivity (pressure or flow).
13. Set the desired PS, if applicable.
14. Set the upper pressure limit.

    Consider 35 cm H₂O as the initial setting and lung protective strategy because the ventilator should not allow the pressure to rise higher than 5 cm H₂O below the upper pressure limit setting and will signal an alarm.¹

15. Ensure that all ventilator alarms are on and set appropriately for the patient’s individual ventilator settings.
16. Remove PPE and clean hands.
17. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Regularly perform a check of ventilator settings, alarms, and measured parameters.
2. Maintain the humidification device and circuit temperature (if applicable) to avoid excessive condensation in the ventilator circuit.
3. Assess the patient’s overall level of comfort and patient-ventilator synchrony.
4. To minimize alveolar derecruitment, consider using a closed-suction device to minimize the number of times the patient is disconnected from the ventilator.

EXPECTED OUTCOMES

• Improved oxygenation
• Improved ventilation
• Improved patient-ventilator synchrony and comfort
• Minimized ventilator-induced lung injury

UNEXPECTED OUTCOMES

• Alveolar overdistention
• Increased work of breathing
• Worsening oxygenation
• Worsening ventilation
• Ventilator-associated event
• Hemodynamic compromise

DOCUMENTATION

• Set target VT
• Set respiratory rate
• Set FIO₂
• Set inspiratory time or I:E ratio
• Set PEEP level
• Set trigger sensitivity
• Set PS, if applicable
• Set upper pressure limit
• Exhaled VT (mandatory breath)
• Exhaled VT (spontaneous breath)
• Minute volume (total)
• Minute volume (spontaneous)
• Respiratory rate (total)
• PIP
• Plateau pressure
• MAP
• Patient tolerance
• Education
• Unexpected outcomes and related interventions

REFERENCES

1. Cairo, J.M. (Ed.). (2024). Chapter 5: Selecting the ventilator and the mode. In Pilbeam’s mechanical ventilation: Physiological and clinical applications (8th ed., pp. 62-83). St. Louis: Elsevier.
2. Holt, G.A., Habib, S.A., Shelledy, D.C. (2020). Chapter 3: Principles of mechanical ventilation. In D.C. Shelledy, J.I. Peters (Eds.), Mechanical ventilation (3rd ed., pp. 95-154). Burlington, MA: Jones & Bartlett Learning.
3. Shelledy, D.C., Peters, J.I. (2020). Chapter 6: Ventilator initiation. In D.C. Shelledy, J.I. Peters (Eds.), Mechanical ventilation (3rd ed., pp. 311-366). Burlington, MA: Jones & Bartlett Learning.

ADDITIONAL READINGS

Matusov, Y. and others. (2020). Use of pressure-regulated volume control in the first 48 hours of hospitalization of mechanically ventilated patients with sepsis or septic shock, with or without ARDS. Journal of the Intensive Care Society, 21(4), 305-311. doi:10.1177/1751143719878969

Clinical Review: Jennifer Elenbaas, MA, BS, RRT, AE-C

Published: April 2025