Overview Of Ventilator Graphics

Terry L. Forrette, M.H.S., RRT

Ventilation Strategies: BiLevel Presentation Overview

Ventilation and Graphics
PEEPHIGH Synchronized Transitions
• Wave Forms
P PEEPLOW THIGH
and Curves
TLOW Synchronized Transitions
• Ventilator
T Management
• BiLevel/APRV
Terry L. Forrette, M.H.S., RRT • Applications

Pressure Wave Forms

• What mode are

we in?
• Differentiating
sensitivity from
synchrony issues
• Adjusting PC
level, I:E ratio,
PSV, Esen

Recognizing Mode of Ventilation

Waveforms
30

A B
C PIP

Plateau

Baseline

Paw Mean Airway Pressure

cmH2O Sec
1 2 3 4 5 6
-10

Wisdom is knowledge applied

www.tlforrette.com TL Forrette & Associates
mail@tlforrette.com 1 (985) 624-9640
 Overview Of Ventilator Graphics
Terry L. Forrette, M.H.S., RRT

Sensitivity versus Synchrony Work to Trigger (Sensitivity)

30

• Sensitivity - trigger effort

– Demand valve design and trigger type
• Synchrony - matching flow to demand A B

– Selection of mode and flow pattern Paw

cmH2O Sec
1 2 3 4 5 6
-10

Patient / Ventilator Synchrony

The Patient Is Out-breathing the Set Flow
Flow Patterns
30

Air Starvation

Paw Sec
cmH2O
1 2 3 4 5 6

What options do we have?

-20

Flow-Time Curve Flow-Time Curve

120 120
INSP INSP
Inspiration

.V .V
SEC SEC
LPM 1 2 3 LPM 1 2 3
4 5 6 4 5 6

Expiration

EXH EXH
120 120

Wisdom is knowledge applied

www.tlforrette.com TL Forrette & Associates
mail@tlforrette.com 2 (985) 624-9640
 Overview Of Ventilator Graphics
Terry L. Forrette, M.H.S., RRT

Typical Flow Curve Flow-Time Curve

120
60 A B INSP
(Inspiratory time)
C INSP
Inspiration
(Expiratory time)

.V
D (Peak flow)

.V SEC SEC
LPM 1 2 3 4 5 6
LPM 1 2 3 4 5 6

E EXH
EXH 120
60

Using Flow Patterns AutoPEEP

• Assessing • Measures trapped

Synchrony air not reflected
by Paw
• Selecting • Influences WOB,
“best” mode hemodynamics
of ventilation and lung
• Identifying mechanics
AutoPEEP • Essential during
PCIRV

Detecting Auto-PEEP Detecting Auto-PEEP

120 120

.V .V
SEC SEC
LPM LPM
1 2 3 4 5 6 1 2 3 4 5 6

Zero flow at end exhalation indicates

equilibration of lung and circuit pressure The transition from expiratory to inspiratory
-120 120 occurs without the expiratory flow returning
to zero

Note: There can still be pressure in the lung behind

airways that are completely obstructed

Wisdom is knowledge applied

www.tlforrette.com TL Forrette & Associates
mail@tlforrette.com 3 (985) 624-9640
 Overview Of Ventilator Graphics
Terry L. Forrette, M.H.S., RRT

AutoPEEP Case Study - 1

Auto-PEEP
Mrs. KT suffered a CHI following an automobile accident.
While being ventilated in VC, using AC, she showed erratic
exhaled volumes, changes in BP, and required frequent
60 60 60 sedation. ABG’s showed moderated hypoxemia, with mild
hypercapnia. Pulse oximetry was unstable and periods of
desaturation were noted when the patient’s exhaled VT’s
became erratic. The following represents a typical flow-time
. . . tracing during a desaturation episode.
V V V
LPM LPM LPM
1 2 1 2 1 2
This patient was generating
A
B C AutoPEEP leading to decreased
SPO2 and erratic exhaled VT.
60 60 60

Pressure - Volume Curves

Volume
Spontaneous Positive Pressure
A Two Dimensional View
Expiration

E
Volume

Inspiration

10 5 0 10 20 30 40

Pressure

Pressure

Using Pressure - Volume Curves Pressure - Volume Curves to

• Assessing lung Assess Lung Mechanics
mechanics
– Compliance, airways Expiration

resistance, & WOB

• Titrating ventilator
Volume

settings Inspiration

– PSV, Rise time,

Esen, TC
• Trouble shooting
– Detecting AutoPEEP, Pressure
circuit leaks

Wisdom is knowledge applied

www.tlforrette.com TL Forrette & Associates
mail@tlforrette.com 4 (985) 624-9640
 Overview Of Ventilator Graphics
Terry L. Forrette, M.H.S., RRT

Normal Compliance
Expiration Expiration
600 mL
Volume

Volume
Inspiration Inspiration

Angle is relative to
compliance

Pressure Pressure 20 cm H2O

C = volume ÷ pressure
C = volume ÷ pressure = 600 ÷ 20
= 30 mL/cmH2O

What Happened To Compliance ?

Decreased Compliance
Expiration
600

400
C = volume ÷ pressure
=?
Volume
Volume

Inspiration

Pressure 40

C = volume ÷ pressure Pressure 15

= 400 ÷ 40
= 10 mL/cm H2O

Compliance Changes Assessing Airways Resistance

Expiration
A
Volume

Volume

Inspiration

Pressure
Pressure

Wisdom is knowledge applied

www.tlforrette.com TL Forrette & Associates
mail@tlforrette.com 5 (985) 624-9640
 Overview Of Ventilator Graphics
Terry L. Forrette, M.H.S., RRT

Increased Inspiratory
Airways Resistance Resistance

Expiratory
Resistance
Volume

Volume
Inspiratory
Resistance

Pressure Pressure

Increased Expiratory Changes In Raw

Resistance

Volume
Volume

A
B

Pressure
Pressure

Lung Overdistension
What Do We Have Here?

Pressure
Big Problems!!! Overshoot
Volume

Volume

Pressure Pressure 15

Wisdom is knowledge applied

www.tlforrette.com TL Forrette & Associates
mail@tlforrette.com 6 (985) 624-9640
 Overview Of Ventilator Graphics
Terry L. Forrette, M.H.S., RRT

Maximizing PIP Levels Upper And Lower Inflection Points

VT VT
LITERS High PEEP set point
A = 400/20 = 20 mL/CWP LITERS
0.6
B = 600/40 = 15 mL/CWP

1.0 0.4

0.6
0.2
0.4 B
A Paw
Paw cmH2O -60 40 20 0 20 40 60
-60 -40 -20 0 20 40 60
cmH2O

Low PEEP set point

Trigger Effort Increased Trigger Effort

VT VT
LITERS LITERS

0.6 0.6

Expiration Expiration
0.4 0.4

Increased
Assisted Breath 0.2 Trigger Effort 0.2
Inspiration Inspiration

Paw Paw
cmH2O -60 40 20 0 20 40 60 cmH2O -60 40 20 0 20 40 60

Assisted Ventilation
What About New Modes?
Breath Types
CP AutoFlow S
VAP
MV AP V Pressure Constant Volume Constant
SI PA
BIPAP
Auto Mode
ILV • PC • Volume using
SP ASB • PS CMV or SIMV
APR ON
V T VS
• BiPAP • Dual Modes
MM • VS/MMV/ASV
V V • BiLevel/APRV
PRVC V PS PL
CM
V CV PAV/PPS & TC
PPS IPPV
PCV

Wisdom is knowledge applied

www.tlforrette.com TL Forrette & Associates
mail@tlforrette.com 7 (985) 624-9640
 Overview Of Ventilator Graphics
Terry L. Forrette, M.H.S., RRT

What is BiLevel? What Is BiLevel?

• Cycling between the two pressure levels can be • Similar to PCV if there is no
synchronized to patient breathing spontaneous breathing
– predetermined time or triggered by patient effort

• The two pressure levels are called PEEPH and

PEEPL
• The two timing levels are TH and TL

PEEPHIGH Synchronized Transitions

P PEEPLOW THIGH P

TLOW Synchronized Transitions

T
T

What Is BiLevel? What Is BiLevel?

• Similar to PCV with no spontaneous
ventilation • Substantial improvements for
spontaneous breathing
• Substantial improvements for
spontaneous breathing – allows spontaneous breathing at both levels
– Allows spontaneous breathing at both – Better synchronization
levels
Spontaneous Breaths Spontaneous Breaths
Synchronized Transitions
PEEPHI PEEPHI
Spontaneous Breaths
P P
PEEPLO PEEPLO

T T

What Is BiLevel? What Is BiLevel?

• Substantial improvements for • Substantial improvements for
spontaneous breathing spontaneous breathing
– allows spontaneous breathing at both levels – allows spontaneous breathing at both levels
– better synchronization
– better synchronization – tidal volume monitoring of upper spont breathing
– Tidal volume monitoring of upper spont – More options for supporting ventilation at upper
breathing level

Tidal Volume Monitoring Pressure Support

Synchronized Transitions Synchronized Transitions
PEEPHI PEEPHI
Spontaneous Breaths
P P
PEEPLO PEEPLO

T T

Wisdom is knowledge applied

www.tlforrette.com TL Forrette & Associates
mail@tlforrette.com 8 (985) 624-9640
 Overview Of Ventilator Graphics
Terry L. Forrette, M.H.S., RRT

BiLevel or APRV? BiLevel Or APRV?

• Is the “real” difference is one of
terminology?
• Original mode called APRV
• Terminology is based on length of TE and Spontaneous Breath

resulting I:E ratio 25

P
Spontaneous Breaths 5
PEEPHI
Spontaneous Breaths
TH TL
Synchronized Transition
P
PEEPLO
3 sec 1 sec
T
T

Clinical Guidelines Upper And Lower Inflection Points

• Starting frequency commonly 10 - 15 VT

• Set high and low times to establish LITERS High = over distention
0.6
release rate and I:E ratio
• Set high and low PEEP levels to 0.4
establish gradient for VT exchange
– maintain PEEPL of 5 cm H2O & keep 0.2

MAP < 35 cm H2O, Pplat < 30 cm H20

Paw
– Use inflection points to select initial cmH2O -60 40 20 0 20 40 60
pressures
Lower = alveolar collapse
• Patient my need initial sedation

Upper And Lower Inflection

Patient Management In BiLevel
Points
VT
LITERS Alveolar over-distention • Manage oxygenation through PEEPL
0.6 and ventilation with PEEPH-L gradient
• Reduce MAP by manipulating PEEPH
PEEPL and frequency
P
0.4

– As spontaneous ventilation increases,

T 0.2
PEEPH and frequency may be reduced
Paw – Gradually decrease gradient to minimal
cmH2O -60 40 20 0 20 40 60
settings (maintain minimal PEEPL level)
• Tailor breath delivery to maximize
Alveolar collapse synchrony with Rise Time and Esens

Wisdom is knowledge applied

www.tlforrette.com TL Forrette & Associates
mail@tlforrette.com 9 (985) 624-9640
 Overview Of Ventilator Graphics
Terry L. Forrette, M.H.S., RRT

APRV Case Study - Mr. WH APRV Case Study - Mr... WH

Using a high to low PEEP gradient of 30 cm
33 year old male with ARDS secondary to
(35/5) H2O , frequency of 12 breath/min, FiO2
lung contusions. 6 days on SIMV/PSV, Cs = .50 the following data were obtained 1 hour after
17, FiO2 .65, PIP 65, PEEP 25, VE 22, APRV was started: Cs 20, PaO2/FiO2 237,
PaO2/FiO2 = 186, PaCO2- PetCO2 = 27 PaCO2-PetCO2 12, VE 14. The patient had a
STV of 4 mL/kg, at a rate of 15 - 20 breaths per
PCIRV not tolerated due to necessity of
minute. He was eventually weaned over the next
NMBA several days to CPAP/PSV
Patient placed on APRV

Clinical Advantages Comments and Questions

• Results in maintenance of lung volume
with a lower PIP, and higher FRC at
similar MAP
• Better cardiovascular performance
(intrathoracic pump)
* Spontaneous Breaths † Synchronized Transition
PCIRC 40
30
cmH2O
20
* * * † * * *†
10
0
10
-20
0 2 4 6 8 10 12s
INSP 80

.
60
40 www.tlforrette.com
20
V 0
L 20
min 40
60
EXP -80

Wisdom is knowledge applied

www.tlforrette.com TL Forrette & Associates
mail@tlforrette.com 10 (985) 624-9640