ventilator waveforms Dr Sanjay Chugh.pptx

VENTILATOR WAVEFORM
ANALYSIS
DR. SANJAY CHUGH
MBBS MD FNB
CONSULTANT ICU
MAHARAJA AGRASEN HOSPITAL

Measured Parameters
Flow
Pressure
Volume
Time

Uses of Flow, Volume, and
Pressure Graphic Display
Confirm mode
Detect auto-PEEP
Determine patient-ventilator synchrony
Assess and adjust trigger levels
Measure the work of breathing
Adjust tidal volume and minimize overdistension
Assess the effect of bronchodilator administration
Detect equipment malfunctions
Determine appropriate PEEP level

Breath Delivery
• Four phases of ventilatory cycle
– trigger
– flow delivery
– cycle
– expiratory phase
• Breaths described by what determines
the above phases

MOST COMMONLY USED
WAVEFORMS
Pressure vs. Time
Flow vs. Time
Volume vs. Time

IFT
EPT
EFT
IPT
Inspiratory
Phase
Expiratory
Phase
IFT(A-B): Inspiratory Flow Time/Phase EFT(C-D): Expiratory Flow Time/Phase
IPT(B-C):Inspiratory Pause Phase EPT(D-A): Expiratory Pause Phase
Inspiratory Time(A-C): IFT+IPT Expiratory Time(C-A) EFT+EPT
A → (Exp. To Insp.)→Trigger (Time Cycled mostly), Depends on Respiratory Rate
C → (Insp.ToExp.) → Volume/ Pressure or Time Cycled
A-C:C-A → I:E Ratio ( Normal 1:2 )
A D
C
B
D
C
B
A
Respiratory Cycle

PRESSURE VS. TIME CURVE
Basics Abnormalities
Spontaneous Breath Increased Airway Resistance
Mechanical Breath Effect of High Inspiratory Flow
Controlled vs Assisted Breath Decreased Lung Compliance
Components of Inflation Pressure Inadequate Inspiratory Flow

Spontaneous vs. Mechanical
Mechanical
Mechanical
Time (sec)
Spontaneous
Spontaneous
Paw
(cm H2O)
Inspiration
Expiration
Expiration
Inspiration
PRESSURE VS TIME GRAPH

PRESSURE-TIME CURVE
1 2 3 4 5 6
20
Sec
Paw
cmH2O
Pressure Ventilation
Volume Ventilation

PATIENT TRIGGERING
1 2 3 4 5 6
30
Sec
Paw
cmH2O
-10

ADEQUATE FLOW DURING
VOLUME CONTROL VENTILATION
30
Time (s)
-10
1 2
aw
P
cmH2O
Adequate flow
3

INADEQUATE FLOW DURING
VOLUME CONTROL VENTILATION
30
Time (s)
-10
1 2
aw
P
cmH2O
Adequate flow
Flow set too low
3

Components of
Inflation Pressure
Components of
Inflation Pressure
Begin Expiration
P
aw
(cm
H
2
O)
Time (sec)
Begin Inspiration
PIP
PIP
Pplateau
( Trans
alveolar
pressure)
Transairway Pressure (PTA)
}
} Exhalation Valve Opens
Expiration
Expiration
Inspiratory Pause

©2000 RespiMedu
Normal
Increased PIP
} Increased PT
A
(increased Airway Resistance)
)
Normal
Normal
PIP
PIP
P
P Plat
Plat
High R
High Ra w
a w
PIP
PIP
P
P Plat
Plat
ed Airway Resistance

Essentials of Ventilator Graphics ©2000 RespiMedu
DECREASED COMPLIANCE
DECREASED COMPLIANCE
Time (sec)
Paw
(cm
H
2
O)
Low Compliance
PIP
PPlat
Normal
Normal
PIP
PPlat
Increased PPlat
(Decreased Compliance)
)
Normal
PIP

Paw
(cm
H
2
O)
Normal
PIP
PPlat
High Raw
PIP
PPlat
Low Compliance
PIP
PPlat
}Increased PTA

PEEP
PEEP
PIP
PPlat
PIP
PPlat
PIP
PPlat
Time (sec)
Paw
(cm
H
2
O)
PEEP

FLOW -TIME CURVE
 Basics of Flow vs. Time Curve
 Spontaneous Breath
 Mechanical Breath
 Typical Flow Patterns
 Inspiratory Flow
 Expiratory Flow
 Recognition of Common Abnormalities
 Obstruction vs. Active Expiration
 Response to Bronchodilators
 Air Trapping/Auto-PEEP

Flow Patterns
Flow Patterns
ACCELERATING
ACCELERATING
DECELERATING
DECELERATING
SINE
SINE
SQUARE
SQUARE

Mechanical vs Spontaneous
Mechanical
Mechanical vs
vs Spontaneous
Spontaneous
Inspiration
Inspiration
Expiration
Expiration
Spontaneous
Spontaneous
Mechanical
Mechanical

Inspiratory Flow Pattern
Inspiratory Flow Pattern
Inspiration
Expiration
Time (sec)
Flow
(L/min)
Flow
(L/min)
Beginning of inspiration
exhalation valve closes
Peak inspiratory flow rate
PIFR
Beginning of expiration
exhalation valve opens
Total cycle time
TCT
Inspiratory
Time
TI
Expiratory Time
TE

Expiratory Flow Pattern
Expiratory Flow Pattern
Inspiration
Expiration
Time (sec)
Flow
(L/min)
Beginning of expiration
exhalation valve opens
Peak Expiratory Flow Rate
PEFR
Duration of
expiratory flow
Expiratory time
TE

FLOW VS.TIME CURVE
1 2 3 4 5 6
SEC
120
120
EXH
INSP
V
.
LPM
Inspiration

FLOW VS.TIME CURVE
1 2 3 4 5 6
SEC
120
120
EXH
INSP
V
.
LPM
Inspiration
Expiration

FLOW VS.TIME CURVE
1 2 3 4 5 6
SEC
120
120
EXH
INSP
Inspiration
V
.
LPM
Constant Flow Descending Ramp

FLOW-TIME CURVE
1 2 3 4 5 6
SEC
120
120
EXH
INSP
Insp. Pause
Expiration
V
.
LPM

Flow
Flow
(L/min)
(L/min)
Time (sec)
Time (sec)
Normal
Normal
Abnormal
Abnormal
Active Inspiration or Asynchrony
Active Inspiration or Asynchrony
Patient’s effort

ng
ng
Normal
Normal
Patient
Patient
Time (sec)
pping
EEP

Air Leak (Flow Trigger)
Air Leak
(Flow Trigger)
Inspiration
Inspiration
Expiration
Expiration
Time (sec)
Time (sec)
Flow
(L/min)
Flow
(L/min)

Obstruction & Active Expiration
Obstruction & Active Expiration
Obstruction Active Expiration
Normal
Abnormal
Flow
(L/min)
PEFR
PEFR

Response to Bronchodilator
Response to Bronchodilator
Before
Time (sec)
Flow
(L/min)
PEFR
After
Long T E
Higher
PEFR
Shorter TE

Volume vs. Time
Volume vs. Time
Inspiration
Inspiration
Expiration
Time (sec)
Time (sec)
Volume
(ml)
Volume
(ml)
Inspiratory Tidal Volume
Inspiratory Tidal Volume
T
TI
I

Active Exhalation
Active Exhalation
Volume (ml)
Volume (ml)
Time (sec)
Time (sec)
From ERV:
Exp. Reserved
Vol.

Air Leak
Air Leak
Volume
(ml)
Volume
(ml)
Time (sec)
Time (sec)
Air Leak
Air Leak

LOOPS
Pressure-Volume Loops
Flow-Volume Loops

FLOW- VOLUME LOOP
Recognition of Common Abnormalities
Air Leak
Auto-PEEP/Air Trapping
Increased Airway Resistance
Airway Secretions/Accumulation of Condensate

Flow-Volume Loop
Flow-Volume Loop
Volume (ml)
Volume (ml)
PEFR
FRC
Inspiration
Expiration
Flow
(L/min)
Flow
(L/min)
PIFR
VT

Airway Secretions/
Water in the Circuit
Airway Secretions/
Airway Secretions/
Inspiration
Inspiration
Expiration
Expiration
Volume (ml)
Volume (ml)
Flow
Flow
(L/min)
(L/min)
Normal
Normal
Abnormal
Abnormal

Essentials o f Ven tilator Graphics ©2000 RespiMed u
Air Trapping
Air Trapping
Inspiration
Expiration
Volume (ml)
Volume (ml)
Flow
(L/min)
Does no t return
Does no t return
to base line
to base line
Normal
Abnormal

Air Trapping
Air Trapping
Inspiration
Expiration
Normal
Normal
Patient
Patient
Time (sec)
Flow
(L/min)
Air Trapping
Auto-PEEP
}
Air Trapping
Air Trapping
Inspiration
Expiration
Volume (ml)
Volume (ml)
Flow
(L/min)
Does not return
Does not return
to baseline
to baseline
Normal
Abnormal
AIR TRAPPING/ AUTO PEEP

INCREASE AIRWAY
RESISTANCE
Essential
s of VentilatorGraph
ics ©2000 RespiM
edu
Paw
(cm
H
Paw
(cm
H
2
2
O)
O)
Nor
mal
Increased PIP
} Increased PTA
(increased Airway Resistance )
)
Normal
Normal
PI
P
PI
P
P
P Pl at
Pl at
High R
High Ra w
a w
PI
P
PI
P
P
P Pl at
Pl at
Increased Airway Resistance

PEEP
PEEP
PIP
PPlat
PIP
PPlat
PIP
PPlat
Time (sec)
Paw
(cm
H
2
O) PEEP
PEEP and P-V Loop
PEEP and P-V Loop
Volume
(mL)
VT
PIP
PIP
Paw (cm H2O)
PEEP
PEEP

Inadequate Inspiratory Flow
Inadequate Inspiratory Flow
P
Paw
aw (cm H
(cm H2
2O)
O)
Volume
Volume
(ml)
(ml)
Normal
Normal
Abnormal
Abnormal
Active Inspiration
Active Inspiration
Active Inspiration

Air Leak
Air Leak
Volume (ml)
Pressure (cm H
Pressure (cm H2
2O)
O)
A ir Leak

AIR LEAK
Air Leak
(Flow Trigger)
Inspiration
Inspiration
Expiration
Expiration
Time (sec)
Time (sec)
Flow
(L/min)
Flow
(L/min)
Air Leak
Air Leak
Volume
(ml)
Volume
(ml)
Time (sec)
Time (sec)
Air Leak
Air Leak
Essentials of Ventilator Graphics ©2000 RespiMedu Essentials of Ventilator Graphics ©2000 RespiMedu
Air Leak
Air Leak
Volume (ml)
P
ressure (cm H
P
ressure (cm H2
2O)
O)
A ir Leak

Essentials of Ventilator G raphics ©2000 RespiMedu
Work of Breathing
Work of Breathing
B: Elastic Work
A: Resistive Work
Pressure (cm H2O)
Volume (ml)
B
B
B
A
A
A

Essen tials o f Ve ntilator Grap hics ©2000 Respi Medu
Increased Raw
Increased Raw
Pressure (cm H
Pressure (cm H2
2O)
O)
Higher PTA
N
orm
al Slope
N
orm
al Slope
Vol
Vol (
( mL
mL)
)
LowerSlope
LowerSlope

Decreased Compliance
Volume(ml)
Pressure (cm H
Pressure (cm H2
2O)
O)
Normal
Normal
Patient
Patient

VOLUME CONTROLLED
VENTILATION
Lung Compliance Changes
and the P-V Loop
and the P-V Loop
Volume (
Volume ( mL
mL)
)
PIP levels
Preset VT
P
Paw
aw (cm H
(cm H 2
2O)
O)
COMPLIANCE
Increased
Normal
Decreased
COMPLIANCE
Increased
Normal
Decreased
Volume T
a rgeted Ventila tion

PRESSURE CONTROLLED
VENTILATION
and the P-V Loop
and the P-V Loop
Volume (
Volume ( mL
mL)
)
Preset PIP
V
T
levels
P
P aw
aw (cm H
(cm H2
2 O)
O)
COMPLIANCE
Increased
Normal
Decreased
COMPLIANCE
Increased
Normal
Decreased
Pressure
Targeted
Ventilation

Spontaneous Breath
Time (sec)
Flow
(L/m)
Pressure
(cm H2O)
Volume
(mL)

IPPV
IPPV
IPPV
FLOW
PRESSURE
VOLUME

Modes of Ventilation on Scalar
Graphics
Graphics
Graphics
FLOW
PRESSURE
VOLUME
Spontaneous Breath
Time (sec)
Flow
(L/m)
Pressure
(cm H2O)
Volume
(mL)
SPONTANEOUS VS. IPPV

Controlled Mode
(Volume-Targeted Ventilation)
Controlled Mode
Preset VT
Volume Cycling
Dependent on
CL & Raw
Time (sec)
Time (sec)
Flow
(L/m)
Pressure
(cm H2O)
Volume
(mL)
Preset Peak Flow
Time triggered, Flow limited, Volume cycled Ventilation

Controlled Mode
(Pressure-Targeted Ventilation)
Controlled Mode
(Pressure-Targeted Ventilation)
Press
ure
Flow
Volume
(L/min)
(cm H2O)
(ml)
Time (sec)
Time (sec)
Time
Time -
-Cycled
Set PC level
Time Triggered, Pressure Limited, Time Cycled Ventilation

Assisted Mode
Assisted Mode
Time (sec)
Time (sec)
Flow
(L/m)
Pressure
(cm H2O)
Volume
(mL)
Preset VT
Volume Cycling
Patient triggered, Flow limited, Volume cycled Ventilation

CMV VS. ASSIST CONTROL
Controlled Mode
Controlled Mode
Preset VT
Volume Cycling
Dependent on
CL & Ra w
Time (sec)
Time (sec)
Flow
(L/m)
Pressure
(cm H2O)
Volume
(mL)
Preset Peak Flow
Time triggered, Flow limited, Volume cycled Ventilation
Assisted Mode
Assisted Mode
Time (sec)
Time (sec)
Flow
(L/m)
Pressure
(cm H2O)
Volume
(mL)
Preset VT
Volume Cycling
Patient triggered, Flow limited, Volume cycled Ventilation

PSV
PSV
Time (sec)
Flow
(L/m)
Pressure
(cm H2O)
Volume
(mL)
Flow Cycling
Flow Cycling
Set PS
level
Set PS
level
Patient Triggered, Flow Cycled, Pressure limited Mode

Spontaneous Breath
Time (sec)
Flow
(L/m)
Pressure
(cm H2O)
Volume
(mL)
PSV
PSV
Time (sec)
Flow
(L/m)
Pressure
(cm H2O)
Volume
(mL)
Flow Cycling
Flow Cycling
Set PS
level
Set PS
level
SPONTANEOUS VS. PSV

CPAP
CPAP
Time (sec)
Time (sec)
CPAP level
Flow
(L/m)
Pressure
(cm H2O)
Volume
(mL)

PSV
PSV
Time (sec)
Flow
(L/m)
Pressure
(cm H2O)
Volume
(mL)
Flow Cycling
Flow Cycling
Set PS
level
Set PS
level
CPAP
CPAP
Time (sec)
Time (sec)
CPAP level
Flow
(L/m)
Pressure
(cm H2O)
Volume
(mL)
PSV Vs. CPAP

TAKE HOME POINTS
 Ventilator waveform analysis is an integral
component in the management of a
mechanically ventilated patient
 Develop a habit of looking at the right
waveform for the given mode of patient
ventilation
 Always look at the inspiratory and expiratory
components of the flow-time waveform
 Don’t hesitate to change the scale or speed of
the waveform to aid in your interpretation

ventilator waveforms Dr Sanjay Chugh.pptx

ventilator waveforms Dr Sanjay Chugh.pptx

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