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The three main types of ventilator waveforms are pressure, flow, and volume. Pressure waveforms show a square shape in pressure modes and a ramp shape in volume modes. Flow waveforms have a square shape in volume modes and a ramp shape in pressure modes. Volume waveforms generally have a mountain peak shape. Pressure/volume loops can be used to assess lung mechanics, airway resistance, compliance, and leaks. Interpreting ventilator graphics allows monitoring of the patient's response to therapy and the ventilator's function.

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VENTILATOR GRAPHICS ver.2.0 Charles S. Williams RRT, AE-C
Purpose • Graphics are waveforms that reflect the patient- ventilator system and their interaction. • Purposes of monitoring graphics: • Allow users to interpret, evaluate, and troubleshoot the ventilator and the patient’s response to the ventilator. • Monitor the patient’s disease status (C and Raw). • Assess the patient’s response to therapy. • Monitor proper ventilator function • Allow fine tuning of ventilator to decrease WOB, optimize ventilation, and maximize patient comfort.
Purpose • A skilled practitioner can use ventilator graphics to assess the status of the patient’s lungs in the same way a cardiologist uses an EKG to view the condition of the heart. • This is especially important for respiratory therapists to help make appropriate recommendations and to ensure proper functioning of the ventilator.
Types of Waveforms Scalars and Loops: • Scalars: Plot pressure, volume, or flow against time. Time is the x-axis. • Loops: Plot pressure or flow against volume. (P/V or F/V). There is no time component.
Types of Waveforms Basic shapes of waveforms: •Generally, the ramp waves are considered the same as exponential shapes, so you really only need to remember three: square, ramp, and sine waves.
Types of Waveforms • Square wave: ▫ Represents a constant or set parameter. ▫ For example, pressure setting in PC mode or flowrate setting in VC mode. • Ramp wave: ▫ Represents a variable parameter ▫ Will vary with changes in lung characteristics ▫ Can be accelerating or decelerating • Sine wave: ▫ Seen with spontaneous, unsupported breathing Basic shapes of waveforms:
Volume Modes Pressure Modes Types of Waveforms Volume Control SIMV (Vol. Control) Pressure Control PRVC SIMV (PRVC) SIMV (Press. Control) Pressure Support Volume Support Pressure Flow Volume Pressure Flow Volume
Question: What are the three types of waveforms? Types of Waveforms  Pressure  Flow  Volume Answer:
• In Volume modes, the shape of the pressure wave will be a ramp for mandatory breaths. • In Pressure modes, the shape of the pressure wave will be a square shape. • This means that pressure is constant during inspiration or pressure is a set parameter. •In Volume modes, adding an inspiratory pause (or hold) will add a small plateau to the waveform. •This is thought to improve distribution of ventilation. Pressure Waveform
•Air trapping (auto-PEEP) •Airway Obstruction •Bronchodilator Response •Respiratory Mechanics (C/Raw) •Active Exhalation •Breath Type (Pressure vs. Volume) •PIP, Pplat •CPAP, PEEP •Asynchrony •Triggering Effort Can be used to assess: Pressure Waveform
Pressure Waveform •The baseline for the pressure waveform will be higher, when PEEP is added. •There will be a negative deflection just before the waveform with patient triggered breaths. 5 15 No patient effort Patient effort PEEP +5
A B 1 2 Inspiratory hold = MAP 1 = Peak Inspiratory Pressure (PIP) 2 = Plateau Pressure (Pplat) A = Airway Resistance (Raw) B = Alveolar Distending Pressure • The area under the entire curve represents the mean airway pressure (MAP). Pressure Waveform
Increased Airway Resistance Decreased Compliance PIP Pplat PIP Pplat A. B. •A -Increase in airway resistance (Raw) causes the PIP to increase, but Pplat pressure remains normal. •B-A decrease in lung compliance causes the entire waveform to increase in size. (More pressure is needed to achieve the same tidal volume). The difference between PIP and Pplat remains normal. Pressure Waveform Raw Raw
Expiratory “hold” applied Set PEEP Auto- PEEP +5 +9 Total- PEEP +14 Air-Trapping (Auto-PEEP) •While performing an expiratory hold maneuver, trapped air will cause the waveform to rise above the baseline. •An acceptable amount of auto-PEEP should be < 5cm H2O Pressure Waveform
A B 1 2 Inspiratory hold = MAP Peak Inspiratory Pressure (PIP) Plateau Pressure (Pplat) Airway Resistance (Raw) Alveolar Distending Pressure 1 = 2 = A = B = Label the parts: Pressure Waveform
Question: An increase in airway resistance causes _____to increase and _____ to remain the same? Answer: PIP increases, Pplat remains the same Pressure Waveform Raw
Volume Waveform • The Volume waveform will generally have a “mountain peak” appearance at the top. It may also have a plateau, or “flattened” area at the peak of the waveform. •There will also be a plateau if an inspiratory pause time is set or inspiratory hold maneuver is applied to the breath.
•Air trapping (auto-PEEP) •Leaks •Tidal Volume •Active Exhalation •Asynchrony Can be used to assess: Volume Waveform
Inspiratory Tidal Volume Exhaled volume returns to baseline Volume Waveform
Volume Waveform Air-Trapping or Leak •If the exhalation side of the waveform doesn’t return to baseline, it could be from air-trapping or there could be a leak (ET tube, vent circuit, chest tube, etc.) Loss of volume
Volume Waveform Question: The volume waveform is most commonly used to assess which two conditions? Answer: Air trapping and leaks
Flow Waveform • In Volume modes, the shape of the flow wave will be square. • This means that flow remains constant or flowrate is a set parameter. • In Pressure modes, the shape of the flow waveform will have ramp pattern. •Some ventilators allow you to select the desired flow pattern in Volume Control mode.
Flow Waveform •Air trapping (auto-PEEP) •Airway Obstruction •Bronchodilator Response •Active Exhalation •Breath Type (Pressure vs. Volume) •Inspiratory Flow •Asynchrony •Triggering Effort Can be used to assess:
Flow Waveform Volume Pressure
Flow Waveform •The decelerating flow pattern may be preferred over the constant flow pattern. The same tidal volume can be delivered, but with a lower peak pressure.
Flow Waveform Auto-Peep (air trapping) •If the expiratory portion of the waveform doesn’t return to baseline before the start of the next breath starts, there could be air trapping. (emphysema, improper I:E ratio) Start of next breath Expiratory flow doesn’t return to baseline = Normal
Flow Waveform Bronchodilator Response •To assess response to bronchodilator therapy, you should see an increase in peak expiratory flow rate. •The expiratory portion of the curve should return to baseline sooner. Peak flow Improved Peak Flow shorter exp. time long exp. time Pre-Bronchodilator Post-Bronchodilator
Flow Waveform Question: This flow pattern indicates what? Answer: Air trapping (auto-PEEP)
Flow Waveform Improved Peak Flow shorter exp. time Pre-Bronchodilator Post-Bronchodilator Question: To assess improvement after a breathing treatment you should see what? Answer: Improved peak flow and shorter expiratory time
Volume Modes Pressure Modes Types of Waveforms •In Pressure Limited, control modes (time-cycled), inspiratory flow should return to baseline. •In support modes (flow-cycled), flow does not return to baseline. Pressure Flow Volume Pressure Flow Volume Volume Control SIMV (Vol. Control) Pressure Control PRVC SIMV (PRVC) SIMV (Press. Control) Pressure Support Volume Support
•The area of no flow indicated by the red line is known as a “zero-flow state”. •This indicates that inspiratory time is too long for this patient. Types of Waveforms
Volume Modes Pressure Modes Types of Waveforms Question: How can I tell what type of mode (or type of breath) is this? Is it Volume or Pressure? Remember the letter “P”. In Pressure modes…The Pressure waveform…has a Plateau. Pressure Control PRVC SIMV (PRVC) SIMV (Press. control) Volume Control SIMV (Vol. control) Pressure Support/ Volume Support Pressure Flow Volume Pressure Flow Volume
Is it a Volume or Pressure mode? Is it a Control (rate) or Support mode? Interpret the mode: Types of Waveforms The pressure waveform has a plateau The flow waveform doesn't return to baseline
15 30 5 250 500 Pressure/Volume Loops
Pressure/Volume Loops • Volume is plotted on the y-axis, Pressure on the x- axis. • Inspiratory curve is upward, Expiratory curve is downward. • Spontaneous breaths go clockwise and positive pressure breaths go counterclockwise. • The bottom of the loop will be at the set PEEP level. It will be at 0 if there’s no PEEP set. • If an imaginary line is drawn down the middle of the loop, the area to the right represents inspiratory resistance and the area to the left represents expiratory resistance.
Pressure/Volume Loops •Lung Overdistention •Airway Obstruction •Bronchodilator Response •Respiratory Mechanics (C/Raw) •WOB •Flow Starvation •Leaks •Triggering Effort Can be used to assess:
15 30 5 Dynamic Compliance Pressure/Volume Loops (Cdyn) •The top part of the P/V loop represents Dynamic compliance (Cdyn). • Cdyn = Δvolume/Δpressure 500 250
Pressure/Volume Loops 15 30 5 250 500 •The P-V loop becomes almost square shaped in pressure modes because of pressure limiting (constant) , during the inspiration.
Pressure/Volume Loops 15 30 5 Overdistention “beaking” •Pressure continues to increase with little or no change in volume, creating a “bird beak”. •Fix by reducing amount of tidal volume delivered 500 250
Pressure/Volume Loops 15 30 5 Airway Resistance •As airway resistance increases, the loop will become wider. •An increase in expiratory resistance is more commonly seen. (Hysteresis) 500 250 Increased inspiratory resistance: kinked ET tube, patient biting tube Increased expiratory resistance: secretions, bronchospasms, etc.
15 30 5 250 500 15 30 5 Pressure/Volume Loops Increased Compliance Decreased Compliance Example: Emphysema, Surfactant Therapy Example: ARDS, CHF, Atelectasis 500 250
15 30 5 Pressure/Volume Loops A Leak •The expiratory portion of the loop doesn’t return to baseline. This indicates a leak. 500 250
15 30 5 Pressure/Volume Loops Lower Inflection Point •The lower inflection point represents the point of alveolar opening (recruitment). •Some lung protection strategies for treating ARDS, suggest setting PEEP just above the lower inflection point. Upper Inflection Point Inflection Points 250 500 (Third Inflection Point)
Pressure/Volume Loops 15 30 5 Question: What does this loop indicate? Answer: Decreased lung compliance. (ARDS, CHF, Atelectasis) 500 250
Pressure/Volume Loops 15 30 5 Question: What is occurring when there is a bird beak appearance on the P/V loop? Answer: Lung overdistention. Pressure continues to increase, while volume remains the same. 500 250
Pressure/Volume Loops Inflection Points Question: Lung protection strategies suggest setting peep at what point? Answer: Just above the lower inflection point 15 30 5 15 30 5 Upper Inflection Point 250 500 (Third Inflection Point) Lower Inflection Point
Flow/Volume Loops 0 200 400 600 20 40 60 -20 -40 -60
Flow/Volume Loops • Flow is plotted on the y axis and volume on the x axis • Flow volume loops used for ventilator graphics are the same as ones used for Pulmonary Function Testing, (usually upside down). • Inspiration is above the horizontal line and expiration is below. • The shape of the inspiratory portion of the curve will match the flow waveform. • The shape of the exp flow curve represents passive exhalation. • Can be used to determine the PIF, PEF, and Vt • Looks circular with spontaneous breaths
Flow/Volume Loops •Air trapping •Airway Obstruction •Airway Resistance •Bronchodilator Response •Insp/Exp Flow •Flow Starvation •Leaks •Water or Secretion accumulation •Asynchrony Can be used to assess:
Flow/Volume Loops 0 200 400 600 20 40 60 -20 -40 -60 Peak Flow Begin Inspiration Begin Expiration
0 0 Flow/Volume Loops •The shape of the inspiratory portion of the curve will match the flow waveform.
Flow/Volume Loops 0 200 400 600 20 40 60 -20 -40 -60 Expiratory part of loop does not return to starting point, indicating a leak. A Leak •If there is a leak, the loop will not meet at the starting point where inhalation starts and exhalation ends. It can also occur with air-trapping. = Normal
0 0 Reduced Peak Flow “scooping” Flow/Volume Loops •The expiratory part of the curve “scoops” with diseases that cause small airway obstruction (high expiratory resistance). e.g. asthma, emphysema. Airway Obstruction “normal PFT view”
0 0 Reduced Peak Flow “scooping” Flow/Volume Loops •The F-V loop appears “upside down” on most ventilators. Airway Obstruction “normal vent graphic view”
Flow/Volume Loops 0 200 400 600 20 40 60 -20 -40 -60 Peak Flow Begin Inspiration Begin Expiration What points on the F/V loop do the arrows indicate?
Flow/Volume Loops 0 200 400 600 20 40 60 -20 -40 -60 Question: When the expiratory side of the loop doesn’t return to baseline, this indicates what? Answer: There is a leak. (ETT cuff, vent circuit)
0 0 Flow/Volume Loops Question: What is the term used for the part of the loop indicated by the arrow? Answer: This is known as “scooping”. It’s caused by airway obstruction.
Air Trapping (auto-PEEP) • Causes: • Insufficient expiratory time • Early collapse of unstable alveoli/airways during exhalation • How to Identify it on the graphics • Pressure wave: while performing an expiratory hold, the waveform rises above baseline. • Flow wave: the expiratory flow doesn’t return to baseline before the next breath begins. • Volume wave: the expiratory portion doesn’t return to baseline. • Flow/Volume Loop: the loop doesn’t meet at the baseline • Pressure/Volume Loop: the loop doesn’t meet at the baseline • How to Fix: • Give a treatment, adjust I-time, increase flow, add PEEP.
Airway Resistance Changes • Causes: • Bronchospasm • ETT problems (too small, kinked, obstructed, patient biting) • High flow rate • Secretion build-up • Damp or blocked expiratory valve/filter • Water in the HME • How to Identify it on the graphics • Pressure wave: PIP increases, but the plateau stays the same • Flow wave: it takes longer for the exp side to reach baseline/exp flow rate is reduced • Volume wave: it takes longer for the exp curve to reach the baseline • Pressure/Volume loop: the loop will be wider. Increase Insp. Resistance will cause it to bulge to the right. Exp resistance, bulges to the left. • Flow/Volume loop: decreased exp flow with a scoop in the exp curve • How to fix • Give a treatment, suction patient, drain water, change HME, change ETT, add a bite block, reduce PF rate, change exp filter.
Compliance Changes • Decreased compliance • Causes  ARDS  Atelectasis  Abdominal distension  CHF  Consolidation  Fibrosis  Hyperinflation  Pneumothorax  Pleural effusion • How to Identify it on the graphics  Pressure wave: PIP and plateau both increase  Pressure/Volume loop: lays more horizontal • Increased compliance • Causes  Emphysema  Surfactant Therapy • How to Identify it on the graphics  Pressure wave: PIP and plateau both decrease  Pressure/Volume loop: Stands more vertical (upright)
Leaks • Causes • Expiratory leak: ETT cuff leak , chest tube leak, BP fistula, NG tube in trachea • Inspiratory leak: loose connections, ventilator malfunction, faulty flow sensor • How to ID it • Pressure wave: Decreased PIP • Volume wave: Expiratory side of wave doesn’t return to baseline • Flow wave: PEF decreased • Pressure/Volume loop: exp side doesn’t return to the baseline • Flow/Volume loop: exp side doesn’t return to baseline • How to fix it • Check possible causes listed above • Do a leak test and make sure all connections are tight
Asynchrony • Causes (Flow, Rate, or Triggering) • Air hunger (flow starvation) • Neurological Injury • Improperly set sensitivity • How to ID it • Pressure wave: patient tries to inhale/exhale in the middle of the waveform, causing a dip in the pressure • Flow wave: patient tries to inhale/exhale in the middle of the waveform, causing erratic flows/dips in the waveform • Pressure/Volume loop: patient makes effort to breath causing dips in loop either Insp/Exp. • Flow/Volume loop: patient makes effort to breath causing dips in loop either Insp/Exp. • How to fix it: • Try increasing the flow rate, decreasing the I-time, or increasing the set rate to “capture” the patient. • Change the mode - sometimes changing from partial to full support will solve the problem • If neurological, may need paralytic or sedative • Adjust sensitivity
Asynchrony Flow Starvation •The inspiratory portion of the pressure wave shows a “dip”, due to inadequate flow.
Asynchrony F/V Loop P/V Loop
Is it a Volume or Pressure mode? Is it a Control (rate) or Support mode? Interpret the mode: Types of Waveforms
Rise Time & Inspiratory Cycle Off %
Rise Time •The inspiratory rise time determines the amount of time it takes to reach the desired airway pressure or peak flow rate. •Used to assess if ventilator is meeting patient’s demand in Pressure Support mode. •In SIMV, rise time becomes a % of the breath cycle.
Rise Time • If rise time is too fast, you can get an overshoot in the pressure wave, creating a pressure “spike”. If this occurs, you need to increase the rise time. This makes the flow valve open a bit more slowly. • If rise time is too slow, the pressure wave becomes rounded or slanted, when it should be more square. This will decrease Vt delivery and may not meet the patient’s inspiratory demands. If this occurs, you will need to decrease the rise time to open the valve faster. too slow too fast pressure spike
Inspiratory Cycle Off •The inspiratory cycle off determines when the ventilator flow cycles from inspiration to expiration, in Pressure Support mode. •The flow-cycling variable is given different names depending on the brand of ventilator. Also know as– •Inspiratory flow termination, •Expiratory flow sensitivity, •Inspiratory flow cycle %, •E-cycle, etc…
Inspiratory Cycle Off •The breath ends when inspiratory flow has dropped to a specific flow value. Inspiration ends pressure flow
Inspiratory Cycle Off •In the above example, the machine is set to cycle inspiration off at 30% of the patient’s peak inspiratory flow. 100% of Patient’s Peak Inspiratory Flow Flow 100% 50% 30% 75%
Inspiratory Cycle Off •A –The cycle off percentage is too high, cycling off too soon. This makes the breath too small. (not enough Vt.) 60% 10% •B – The cycle off percentage is too low, making the breath too long. This forces the patient to actively exhale (increase WOB), creating an exhalation “spike”. Exhalation spike A B 100% 100%
Rise Time Question: The red portion of the waveform indicates that rise time is what? Answer: It indicates that the rise time is too slow
Inspiratory Cycle Off Flow 100% 30% Question: This pressure support breath is set to cycle of at 30% of the patient’s ________. Answer: Peak Inspiratory Flow
Sources: • Rapid Interpretation of Ventilator Waveforms • Ventilator Waveform Analysis – Susan Pearson • Golden Moments in Mechanical Ventilation – Maquet, inc. • Servo-I Graphics – Maquet, inc.
VENTILATOR GRAPHICS Thank You!

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Chap10.pdf

  • 1.
  • 2.
    Purpose • Graphics arewaveforms that reflect the patient- ventilator system and their interaction. • Purposes of monitoring graphics: • Allow users to interpret, evaluate, and troubleshoot the ventilator and the patient’s response to the ventilator. • Monitor the patient’s disease status (C and Raw). • Assess the patient’s response to therapy. • Monitor proper ventilator function • Allow fine tuning of ventilator to decrease WOB, optimize ventilation, and maximize patient comfort.
  • 3.
    Purpose • A skilledpractitioner can use ventilator graphics to assess the status of the patient’s lungs in the same way a cardiologist uses an EKG to view the condition of the heart. • This is especially important for respiratory therapists to help make appropriate recommendations and to ensure proper functioning of the ventilator.
  • 4.
    Types of Waveforms Scalarsand Loops: • Scalars: Plot pressure, volume, or flow against time. Time is the x-axis. • Loops: Plot pressure or flow against volume. (P/V or F/V). There is no time component.
  • 5.
    Types of Waveforms Basicshapes of waveforms: •Generally, the ramp waves are considered the same as exponential shapes, so you really only need to remember three: square, ramp, and sine waves.
  • 6.
    Types of Waveforms •Square wave: ▫ Represents a constant or set parameter. ▫ For example, pressure setting in PC mode or flowrate setting in VC mode. • Ramp wave: ▫ Represents a variable parameter ▫ Will vary with changes in lung characteristics ▫ Can be accelerating or decelerating • Sine wave: ▫ Seen with spontaneous, unsupported breathing Basic shapes of waveforms:
  • 7.
    Volume Modes PressureModes Types of Waveforms Volume Control SIMV (Vol. Control) Pressure Control PRVC SIMV (PRVC) SIMV (Press. Control) Pressure Support Volume Support Pressure Flow Volume Pressure Flow Volume
  • 8.
    Question: What arethe three types of waveforms? Types of Waveforms  Pressure  Flow  Volume Answer:
  • 9.
    • In Volumemodes, the shape of the pressure wave will be a ramp for mandatory breaths. • In Pressure modes, the shape of the pressure wave will be a square shape. • This means that pressure is constant during inspiration or pressure is a set parameter. •In Volume modes, adding an inspiratory pause (or hold) will add a small plateau to the waveform. •This is thought to improve distribution of ventilation. Pressure Waveform
  • 10.
    •Air trapping (auto-PEEP) •AirwayObstruction •Bronchodilator Response •Respiratory Mechanics (C/Raw) •Active Exhalation •Breath Type (Pressure vs. Volume) •PIP, Pplat •CPAP, PEEP •Asynchrony •Triggering Effort Can be used to assess: Pressure Waveform
  • 11.
    Pressure Waveform •The baselinefor the pressure waveform will be higher, when PEEP is added. •There will be a negative deflection just before the waveform with patient triggered breaths. 5 15 No patient effort Patient effort PEEP +5
  • 12.
    A B 1 2 Inspiratory hold = MAP 1= Peak Inspiratory Pressure (PIP) 2 = Plateau Pressure (Pplat) A = Airway Resistance (Raw) B = Alveolar Distending Pressure • The area under the entire curve represents the mean airway pressure (MAP). Pressure Waveform
  • 13.
    Increased Airway ResistanceDecreased Compliance PIP Pplat PIP Pplat A. B. •A -Increase in airway resistance (Raw) causes the PIP to increase, but Pplat pressure remains normal. •B-A decrease in lung compliance causes the entire waveform to increase in size. (More pressure is needed to achieve the same tidal volume). The difference between PIP and Pplat remains normal. Pressure Waveform Raw Raw
  • 14.
    Expiratory “hold” applied Set PEEP Auto- PEEP +5 +9 Total- PEEP +14 Air-Trapping(Auto-PEEP) •While performing an expiratory hold maneuver, trapped air will cause the waveform to rise above the baseline. •An acceptable amount of auto-PEEP should be < 5cm H2O Pressure Waveform
  • 15.
    A B 1 2 Inspiratory hold = MAP PeakInspiratory Pressure (PIP) Plateau Pressure (Pplat) Airway Resistance (Raw) Alveolar Distending Pressure 1 = 2 = A = B = Label the parts: Pressure Waveform
  • 16.
    Question: An increasein airway resistance causes _____to increase and _____ to remain the same? Answer: PIP increases, Pplat remains the same Pressure Waveform Raw
  • 17.
    Volume Waveform • TheVolume waveform will generally have a “mountain peak” appearance at the top. It may also have a plateau, or “flattened” area at the peak of the waveform. •There will also be a plateau if an inspiratory pause time is set or inspiratory hold maneuver is applied to the breath.
  • 18.
    •Air trapping (auto-PEEP) •Leaks •TidalVolume •Active Exhalation •Asynchrony Can be used to assess: Volume Waveform
  • 19.
    Inspiratory Tidal Volume Exhaledvolume returns to baseline Volume Waveform
  • 20.
    Volume Waveform Air-Trapping orLeak •If the exhalation side of the waveform doesn’t return to baseline, it could be from air-trapping or there could be a leak (ET tube, vent circuit, chest tube, etc.) Loss of volume
  • 21.
    Volume Waveform Question: Thevolume waveform is most commonly used to assess which two conditions? Answer: Air trapping and leaks
  • 22.
    Flow Waveform • InVolume modes, the shape of the flow wave will be square. • This means that flow remains constant or flowrate is a set parameter. • In Pressure modes, the shape of the flow waveform will have ramp pattern. •Some ventilators allow you to select the desired flow pattern in Volume Control mode.
  • 23.
    Flow Waveform •Air trapping(auto-PEEP) •Airway Obstruction •Bronchodilator Response •Active Exhalation •Breath Type (Pressure vs. Volume) •Inspiratory Flow •Asynchrony •Triggering Effort Can be used to assess:
  • 24.
  • 25.
    Flow Waveform •The deceleratingflow pattern may be preferred over the constant flow pattern. The same tidal volume can be delivered, but with a lower peak pressure.
  • 26.
    Flow Waveform Auto-Peep (airtrapping) •If the expiratory portion of the waveform doesn’t return to baseline before the start of the next breath starts, there could be air trapping. (emphysema, improper I:E ratio) Start of next breath Expiratory flow doesn’t return to baseline = Normal
  • 27.
    Flow Waveform Bronchodilator Response •Toassess response to bronchodilator therapy, you should see an increase in peak expiratory flow rate. •The expiratory portion of the curve should return to baseline sooner. Peak flow Improved Peak Flow shorter exp. time long exp. time Pre-Bronchodilator Post-Bronchodilator
  • 28.
    Flow Waveform Question: Thisflow pattern indicates what? Answer: Air trapping (auto-PEEP)
  • 29.
    Flow Waveform Improved PeakFlow shorter exp. time Pre-Bronchodilator Post-Bronchodilator Question: To assess improvement after a breathing treatment you should see what? Answer: Improved peak flow and shorter expiratory time
  • 30.
    Volume Modes PressureModes Types of Waveforms •In Pressure Limited, control modes (time-cycled), inspiratory flow should return to baseline. •In support modes (flow-cycled), flow does not return to baseline. Pressure Flow Volume Pressure Flow Volume Volume Control SIMV (Vol. Control) Pressure Control PRVC SIMV (PRVC) SIMV (Press. Control) Pressure Support Volume Support
  • 31.
    •The area ofno flow indicated by the red line is known as a “zero-flow state”. •This indicates that inspiratory time is too long for this patient. Types of Waveforms
  • 32.
    Volume Modes PressureModes Types of Waveforms Question: How can I tell what type of mode (or type of breath) is this? Is it Volume or Pressure? Remember the letter “P”. In Pressure modes…The Pressure waveform…has a Plateau. Pressure Control PRVC SIMV (PRVC) SIMV (Press. control) Volume Control SIMV (Vol. control) Pressure Support/ Volume Support Pressure Flow Volume Pressure Flow Volume
  • 33.
    Is it aVolume or Pressure mode? Is it a Control (rate) or Support mode? Interpret the mode: Types of Waveforms The pressure waveform has a plateau The flow waveform doesn't return to baseline
  • 34.
  • 35.
    Pressure/Volume Loops • Volumeis plotted on the y-axis, Pressure on the x- axis. • Inspiratory curve is upward, Expiratory curve is downward. • Spontaneous breaths go clockwise and positive pressure breaths go counterclockwise. • The bottom of the loop will be at the set PEEP level. It will be at 0 if there’s no PEEP set. • If an imaginary line is drawn down the middle of the loop, the area to the right represents inspiratory resistance and the area to the left represents expiratory resistance.
  • 36.
    Pressure/Volume Loops •Lung Overdistention •AirwayObstruction •Bronchodilator Response •Respiratory Mechanics (C/Raw) •WOB •Flow Starvation •Leaks •Triggering Effort Can be used to assess:
  • 37.
    15 30 5 Dynamic Compliance Pressure/Volume Loops (Cdyn) •Thetop part of the P/V loop represents Dynamic compliance (Cdyn). • Cdyn = Δvolume/Δpressure 500 250
  • 38.
    Pressure/Volume Loops 15 30 5 250 500 •TheP-V loop becomes almost square shaped in pressure modes because of pressure limiting (constant) , during the inspiration.
  • 39.
    Pressure/Volume Loops 15 30 5 Overdistention “beaking” •Pressurecontinues to increase with little or no change in volume, creating a “bird beak”. •Fix by reducing amount of tidal volume delivered 500 250
  • 40.
    Pressure/Volume Loops 15 30 5 AirwayResistance •As airway resistance increases, the loop will become wider. •An increase in expiratory resistance is more commonly seen. (Hysteresis) 500 250 Increased inspiratory resistance: kinked ET tube, patient biting tube Increased expiratory resistance: secretions, bronchospasms, etc.
  • 41.
    15 30 5 250 500 15 30 5 Pressure/VolumeLoops Increased Compliance Decreased Compliance Example: Emphysema, Surfactant Therapy Example: ARDS, CHF, Atelectasis 500 250
  • 42.
    15 30 5 Pressure/Volume Loops ALeak •The expiratory portion of the loop doesn’t return to baseline. This indicates a leak. 500 250
  • 43.
    15 30 5 Pressure/Volume Loops Lower InflectionPoint •The lower inflection point represents the point of alveolar opening (recruitment). •Some lung protection strategies for treating ARDS, suggest setting PEEP just above the lower inflection point. Upper Inflection Point Inflection Points 250 500 (Third Inflection Point)
  • 44.
    Pressure/Volume Loops 15 30 5 Question:What does this loop indicate? Answer: Decreased lung compliance. (ARDS, CHF, Atelectasis) 500 250
  • 45.
    Pressure/Volume Loops 15 30 5 Question:What is occurring when there is a bird beak appearance on the P/V loop? Answer: Lung overdistention. Pressure continues to increase, while volume remains the same. 500 250
  • 46.
    Pressure/Volume Loops Inflection Points Question:Lung protection strategies suggest setting peep at what point? Answer: Just above the lower inflection point 15 30 5 15 30 5 Upper Inflection Point 250 500 (Third Inflection Point) Lower Inflection Point
  • 47.
    Flow/Volume Loops 0 200 400600 20 40 60 -20 -40 -60
  • 48.
    Flow/Volume Loops • Flowis plotted on the y axis and volume on the x axis • Flow volume loops used for ventilator graphics are the same as ones used for Pulmonary Function Testing, (usually upside down). • Inspiration is above the horizontal line and expiration is below. • The shape of the inspiratory portion of the curve will match the flow waveform. • The shape of the exp flow curve represents passive exhalation. • Can be used to determine the PIF, PEF, and Vt • Looks circular with spontaneous breaths
  • 49.
    Flow/Volume Loops •Air trapping •AirwayObstruction •Airway Resistance •Bronchodilator Response •Insp/Exp Flow •Flow Starvation •Leaks •Water or Secretion accumulation •Asynchrony Can be used to assess:
  • 50.
    Flow/Volume Loops 0 200 400600 20 40 60 -20 -40 -60 Peak Flow Begin Inspiration Begin Expiration
  • 51.
    0 0 Flow/Volume Loops •Theshape of the inspiratory portion of the curve will match the flow waveform.
  • 52.
    Flow/Volume Loops 0 200 400600 20 40 60 -20 -40 -60 Expiratory part of loop does not return to starting point, indicating a leak. A Leak •If there is a leak, the loop will not meet at the starting point where inhalation starts and exhalation ends. It can also occur with air-trapping. = Normal
  • 53.
    0 0 Reduced Peak Flow “scooping” Flow/Volume Loops •Theexpiratory part of the curve “scoops” with diseases that cause small airway obstruction (high expiratory resistance). e.g. asthma, emphysema. Airway Obstruction “normal PFT view”
  • 54.
    0 0 Reduced Peak Flow “scooping” Flow/Volume Loops •TheF-V loop appears “upside down” on most ventilators. Airway Obstruction “normal vent graphic view”
  • 55.
    Flow/Volume Loops 0 200 400600 20 40 60 -20 -40 -60 Peak Flow Begin Inspiration Begin Expiration What points on the F/V loop do the arrows indicate?
  • 56.
    Flow/Volume Loops 0 200 400600 20 40 60 -20 -40 -60 Question: When the expiratory side of the loop doesn’t return to baseline, this indicates what? Answer: There is a leak. (ETT cuff, vent circuit)
  • 57.
    0 0 Flow/Volume Loops Question:What is the term used for the part of the loop indicated by the arrow? Answer: This is known as “scooping”. It’s caused by airway obstruction.
  • 58.
    Air Trapping (auto-PEEP) •Causes: • Insufficient expiratory time • Early collapse of unstable alveoli/airways during exhalation • How to Identify it on the graphics • Pressure wave: while performing an expiratory hold, the waveform rises above baseline. • Flow wave: the expiratory flow doesn’t return to baseline before the next breath begins. • Volume wave: the expiratory portion doesn’t return to baseline. • Flow/Volume Loop: the loop doesn’t meet at the baseline • Pressure/Volume Loop: the loop doesn’t meet at the baseline • How to Fix: • Give a treatment, adjust I-time, increase flow, add PEEP.
  • 59.
    Airway Resistance Changes •Causes: • Bronchospasm • ETT problems (too small, kinked, obstructed, patient biting) • High flow rate • Secretion build-up • Damp or blocked expiratory valve/filter • Water in the HME • How to Identify it on the graphics • Pressure wave: PIP increases, but the plateau stays the same • Flow wave: it takes longer for the exp side to reach baseline/exp flow rate is reduced • Volume wave: it takes longer for the exp curve to reach the baseline • Pressure/Volume loop: the loop will be wider. Increase Insp. Resistance will cause it to bulge to the right. Exp resistance, bulges to the left. • Flow/Volume loop: decreased exp flow with a scoop in the exp curve • How to fix • Give a treatment, suction patient, drain water, change HME, change ETT, add a bite block, reduce PF rate, change exp filter.
  • 60.
    Compliance Changes • Decreasedcompliance • Causes  ARDS  Atelectasis  Abdominal distension  CHF  Consolidation  Fibrosis  Hyperinflation  Pneumothorax  Pleural effusion • How to Identify it on the graphics  Pressure wave: PIP and plateau both increase  Pressure/Volume loop: lays more horizontal • Increased compliance • Causes  Emphysema  Surfactant Therapy • How to Identify it on the graphics  Pressure wave: PIP and plateau both decrease  Pressure/Volume loop: Stands more vertical (upright)
  • 61.
    Leaks • Causes • Expiratoryleak: ETT cuff leak , chest tube leak, BP fistula, NG tube in trachea • Inspiratory leak: loose connections, ventilator malfunction, faulty flow sensor • How to ID it • Pressure wave: Decreased PIP • Volume wave: Expiratory side of wave doesn’t return to baseline • Flow wave: PEF decreased • Pressure/Volume loop: exp side doesn’t return to the baseline • Flow/Volume loop: exp side doesn’t return to baseline • How to fix it • Check possible causes listed above • Do a leak test and make sure all connections are tight
  • 62.
    Asynchrony • Causes (Flow,Rate, or Triggering) • Air hunger (flow starvation) • Neurological Injury • Improperly set sensitivity • How to ID it • Pressure wave: patient tries to inhale/exhale in the middle of the waveform, causing a dip in the pressure • Flow wave: patient tries to inhale/exhale in the middle of the waveform, causing erratic flows/dips in the waveform • Pressure/Volume loop: patient makes effort to breath causing dips in loop either Insp/Exp. • Flow/Volume loop: patient makes effort to breath causing dips in loop either Insp/Exp. • How to fix it: • Try increasing the flow rate, decreasing the I-time, or increasing the set rate to “capture” the patient. • Change the mode - sometimes changing from partial to full support will solve the problem • If neurological, may need paralytic or sedative • Adjust sensitivity
  • 63.
    Asynchrony Flow Starvation •The inspiratoryportion of the pressure wave shows a “dip”, due to inadequate flow.
  • 64.
  • 65.
    Is it aVolume or Pressure mode? Is it a Control (rate) or Support mode? Interpret the mode: Types of Waveforms
  • 66.
  • 67.
    Rise Time •The inspiratoryrise time determines the amount of time it takes to reach the desired airway pressure or peak flow rate. •Used to assess if ventilator is meeting patient’s demand in Pressure Support mode. •In SIMV, rise time becomes a % of the breath cycle.
  • 68.
    Rise Time • Ifrise time is too fast, you can get an overshoot in the pressure wave, creating a pressure “spike”. If this occurs, you need to increase the rise time. This makes the flow valve open a bit more slowly. • If rise time is too slow, the pressure wave becomes rounded or slanted, when it should be more square. This will decrease Vt delivery and may not meet the patient’s inspiratory demands. If this occurs, you will need to decrease the rise time to open the valve faster. too slow too fast pressure spike
  • 69.
    Inspiratory Cycle Off •Theinspiratory cycle off determines when the ventilator flow cycles from inspiration to expiration, in Pressure Support mode. •The flow-cycling variable is given different names depending on the brand of ventilator. Also know as– •Inspiratory flow termination, •Expiratory flow sensitivity, •Inspiratory flow cycle %, •E-cycle, etc…
  • 70.
    Inspiratory Cycle Off •Thebreath ends when inspiratory flow has dropped to a specific flow value. Inspiration ends pressure flow
  • 71.
    Inspiratory Cycle Off •Inthe above example, the machine is set to cycle inspiration off at 30% of the patient’s peak inspiratory flow. 100% of Patient’s Peak Inspiratory Flow Flow 100% 50% 30% 75%
  • 72.
    Inspiratory Cycle Off •A–The cycle off percentage is too high, cycling off too soon. This makes the breath too small. (not enough Vt.) 60% 10% •B – The cycle off percentage is too low, making the breath too long. This forces the patient to actively exhale (increase WOB), creating an exhalation “spike”. Exhalation spike A B 100% 100%
  • 73.
    Rise Time Question: Thered portion of the waveform indicates that rise time is what? Answer: It indicates that the rise time is too slow
  • 74.
    Inspiratory Cycle Off Flow 100% 30% Question:This pressure support breath is set to cycle of at 30% of the patient’s ________. Answer: Peak Inspiratory Flow
  • 75.
    Sources: • Rapid Interpretationof Ventilator Waveforms • Ventilator Waveform Analysis – Susan Pearson • Golden Moments in Mechanical Ventilation – Maquet, inc. • Servo-I Graphics – Maquet, inc.
  • 76.