VENTILATOR GRAPHICS

Purpose
Graphics are waveforms that reflect the patientventilator system and their interaction Purpose of monitoring graphics includes
Monitors the patients disease status (C and Raw) Calculates respiratory mechanics Assesses patient response to therapy Monitors ventilator function Allows fine tuning of ventilator to decrease WOB and optimize ventilation Allows user to interpret, evaluate, and troubleshoot ventilator and patients response to ventilator

Types of waveforms
Scalars: plot pressure/volume/flow against timetime is the x axis Loops: plot pressure/volume/flow against each otherthere is no time component Six basic waveforms:
Rectangular: AKA swuare wave Descending ramp: AKA decelerating ramp Ascending ramp: AKA accelerating ramp Sinusoidal: AKA sine wave Exponential rising Exponential decaying

Types of waveforms seen

Pressure waveforms
Rectangular Exponential rise Sine

Volume waveforms
Ascending ramp Sinusoidal

Flow waveforms
Rectangular Sinusoidal Ascending ramp Descending ramp Exponential decay
Flow Patterns

SQUARE

DECELERATING

ACCELERATING

SINE

Pressure-Time Scalar

Machine-triggered breaths have no negative deflection at the start Patient triggered breaths may have a negative deflection at the start if the breath is being pressure triggeredthe greater the patient effort to trigger the breath, the greater the negative deflection seenno deflection see with flow triggering In volume modes, the shape will be exponential rise for mandatory breaths and sinusoidal for spontaneous breathsif PS is added to spontaneous breaths, then the waveform will be square on the spontaneous breaths In pressure modes, the shape will be rectangular for mandatory breaths and sinusoidal for spontaneous breathsif PS added to the spontaneous breaths, they will be rectangular also If PEEP is added, the baseline during expiration will be above zero The area under the entire curve equals the Paw (mean airway pressure)

Components of Inflation Pressure

1 2 Paw (cm H2O) 1. PIP 2. Pplat/Alveolar Pressure A. Airway Resistance B. Distending Pressure

B Time (sec)

Begin Inspiration

Begin Expiration

Use of Pressure-Time Scalars

Patient Air trapping (auto-PEEP) Ventilator Breath type Pt-Vent Interaction Asynchrony

Airway PIP and plateau obstruction Active exhalation PEEP/CPAP Bronchodilator Pressure waveform response change Resp mechanics It/Et/I:E (C/Raw)

Triggering effort

Volume-Time Scalar
Ascending ramp shape if a square wave flow pattern is usedsinusoidal if the sine wave flow pattern is usedexponential rise if the decelerating flow pattern is used Plateaus at the peak of the curve in PC/PS If the exhalation side of the curve doesnt return to baseline, it could be auto-PEEP or there could be a leak (eg-around ETT or through a chest tube)

Volume vs Time Scalar

Inspiratory Tidal Volume

Volume (ml)

Inspiration Expiration

TI

Time (sec)

Use of Volume-Time Scalars

Patient Air trapping (auto-PEEP) Active exhalation Ventilator Breath types Pt-Vent Interaction Asynchrony

Volume waveform shape Vt

Leaks

Flow-Time Scalars
No evidence supports one flow pattern over anotherthe square wave might distribute gas more evenly in patients with a unilateral lung dxdecelerating ramp may distribute gas more evenly because the high burst of flow at the beginning would pop alveoli open and allow for gas exchange during the entire breath If expiratory flow doesnt return to baseline before the next breath starts, theres auto-PEEP present (air trapping is occurring) Volume control on some vents allows you to select the flow pattern you want All pressure breaths (PC, PS, PRVC, VS) will have a decelerating ramp flow pattern CPAP has a sinusoidal flow pattern unless PS has been added

Use of Flow-Time Scalars

Patient Ventilator Pt-Vent Interaction

Air trapping
Airway obst

Breath types
Flow waveform shape

Asynchrony
Triggering effort

Active exhalation
Bronchodilator response Resp mechanics (C/Raw)

Inspiratory flow
Flow starvation (vol vent) Adjustment of It (Press vent) Adjustment of rise time

Pressure-Volume Loops
Volume is plotted on the y axis and pressure on the x axis (can also be plotted the other way around) Inspiratory curve is upward and 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 or be at 0 if theres no PEEP set I starts and E ends at the bottom of the loopI ends and E starts at the top of the loop The loop is almost square in PC/PS because of pressure limiting during I

Pressure-Volume Loop
VT
Ex pi ra tio n

In sp ira tio n

Volume (mL) mL)

Paw (cm H2O)

Essentials of Ventilator Graphics

PIP
2000

RespiMedu

Abnormal PV Loops
If an imaginary line is drawn down the middle of the loop, the area to the right represents inspiratory resistance/WOB and the area to the left represents expiratory resistance/WOB (just the opposite for spont breaths- I is to the left and E is to the right) The more vertical the loop lays, the lower the lung C, the more horizontal it lays, the higher the lung C The fatter the loop, the higher the airway resistanceyou can tell if its I or E resistance by looking at whether the right or left side bulges out more A bird beak at the top of the loop represents overdistension A pig tail at the bottom indicates patient triggeringthe bigger the pig tail, the higher the patient WOB to trigger the breath The loop wont meet at the bottom with airtrapping or leaks

Use of PV Loops
Patient Airway obst Active exhalation Bronchodilator response Lung overdistension Resp mechanics WOB Ventilator Adjusting PS levels Flow starvation Leaks Pt-Vent Interaction Triggering effort

Flow-Volume Loops
Flow is plotted on the y axis and volume on the x axis Inspiration is above the horizontal line and expiration is below (some vents reverse this and I is below while E is above) The shape of the insp flow curve will match whats set on the ventilator The shape of the exp flow curve represents passive exhalationits long and more drawn out in patients with less recoil Can be used to determine the PIF, PEF, and Vt Looks circular with spontaneous breaths Looks squared but set at an angle with PC/PS breaths

Flow-Volume Loop
Inspiration
Flow (L/min)

1 4 3

Volume (ml)

FRC 2 Expiration
Essentials of Ventilator Graphics
2000

RespiMedu

Abnormal FV Loops
The expiratory curve scoops with high expiratory resistance If the patient is air trapping or has a leak, the loop will not meet at the left side where I starts/E ends If water/secretions are building up in the airway or circuit, the loop becomes very jagged

Use of FV Loops
Patient Air trapping Airway obst Airway resistance Active exhalation Bronchodilator response Ventilator Pt-Vent Interaction Insp flow asynchrony Exp flow Flow starvation Vt Leaks Water or secretion buildup

Air Trapping (auto-PEEP)

Causes:
increased exp resistance (either in the airways or in the circuit) Insufficient expiratory time Early collapse of unstable alveoli/airways during exhalation

How to ID it on the graphics

Pressure time: while performing an expiratory hold, the waveform rises above baseline Flow-time: the exp flow doesnt return to baseline before the next breath begins Volume-time: the exp portion doesnt return to baseline FV Loop: the loop doesnt meet at the baseline PV Loop: the loop doesnt meet at the baseline

How to Fix:
ID the cause and resolve Give a treatment, suction, change the HME, decrease It/increase flow, add PEEP

Air Trapping
Flow (L/min) Inspiration
Normal Patient

Time (sec) }
Air Trapping AutoAuto-PEEP

Expiration

Airway Resistance Changes

Causes:
Bronchospasm Damp or blocked expiratory valve/filter ETT problems (too small, kinked, obstructed, patient biting) High flow Secretion build-up Water in the HME

Airway Resistance Changes

How to ID
Pressure-time: the PIP increases but the plateau stays the same Volume-time: it takes longer for the exp curve to reach the baseline Flow-time: it takes longer for the exp curve to reach baseline and the exp flow rate is reduced FV loop: decreased exp flow with a scoop in the exp curve PV loop: the loop will be fatterif it bulges to the right, its insp resistance and to the left its exp

How to fix
ID cause and fix it Give a tx, sx, drain water, change HME, change ETT, add a bite block, decrease PF rate, change exp filter

PIP
Normal
PIP Pplat

vs

Pplat
PIP

High Raw
Pplat

Paw (cm H2O)

PIP

High Flow
Pplat

PIP

Low CL
Pplat

Time (sec)

Compliance Changes
Decreased compliance
Causes
ARDS Atelectasis Abdominal distension CHF Consolidation Fibrosis Hyperinflation Pneumothorax Pleural effusion Just about every pulm dx there is

Lung Compliance Changes in the P-V Loop

VT
Volume Targeted Ventilation

COMPLIANCE COMPLIANCE Volume (mL ) (mL)

Normal Increased Decreased

PIP levels
Paw (cm H2O)
2000

Essentials of Ventilator Graphics

RespiMedu

How to ID it
Pressure-time: the PIP and plateau both increase PV loop: lays more horizontal

Compliance changes
Increased compliance
Causes
emphysema Surfactant therapy

How to ID it
Pressure-time: PIP and plateau both decrease PV loop: stands more vertical (upright)

Active Exhalation
Causes
Patient is exhaling below FRC due to air trapping (vol dumping) Pain Positional change Equipement calibration problem

How to ID it
Volume-time: exp waveform goes below the baseline PV loop: exp loop goes past the zero point FV loop: exp part goes past the zero point

How to fix it
Reduce air-trapping Calibrate equipment Relieve pain

Partial Obstruction
Causes
Suction catheter left in ETT Tissue flap Mucus plug Water/secretions in the circuit or airway

How to ID It
Flow-volume: flow is not steady and constant, but varies as the obst moves around PV loop: jagged instead of smooth FV loop: jagged with fluctuating flow

How to fix it
Pull catheter out of ETT Suction Drain water Change HME Move the ETT

Overdistension
Causes
Vt set too high (vol vent) Pressure set too high (press vent) Could occur in pressure vent with C or Raw changes
Overdistension
Paw rises with little or no change in VT

Paw (cm H2O)

How to ID it
PV loop: bird beak at the top of the loop
Essentials of Ventilator Graphics

Pressure (cm H2O)

2000

RespiMedu

How to fix it
Reduce Vt (vol vent) Reduce pressure (P vent)

Leaks
Causes
Expiratory leak: air leak through a chest tube, BP fistula, ETT cuff leak, NG tube in trachea Inspiratory leak: loose connections, ventilator malfunction, faulty flow sensor

How to ID it
Pressure-time: decreased PIP Volume-time: decreased Vtexp leaks keep exp Vt from returning to baseline Flow-time: PEF decreases PV loop: exp side doesnt return to the baseline FV loop: exp part doesnt return to baseline

How to fix it
ID source of leak and fix it Do a leak test and make sure all connections are tight

Rate Asynchrony
Causes
Neurological injury/swelling Air hunger

How to ID it
Pressure-time: patient tries to inhale/exhale in the middle of the waveform, causing a dip in the pressure Flow-time: patient tries to inhale/exhale in the middle of the waveform, causing erratic flows/dips in the waveform PV loop: dips in the loop during either I or E, showing patient efforts to breathe FL loop: dips in the loop during either I or E, showing patient efforts to breathe

How to fix it: if neurological, may need paralytic or sedative to reduce respiratory driveif air hunger, adjust settings (try increasing the flow rate/decreasing the It or increasing the set rate to capture the patient) or changing the mode - sometimes changing from partial to full support will solve the problem

Flow Asynchrony
Causes:flow rate set incorrectly for the patient demands (volume vent onlyin pressure ventilation the flow is a function of the pressure setting and the patients lung characteristics you dont set it or have any control over it) How to ID It
Pressure-time curve: patient pulls off the pressure curve and it becomes concave Pressure-volume loop: the inspiratory side will scoop inward with a decrease in pressure

How to fix it: increase the peak flow setting

Trigger Asynchrony
Causes: sensitivity not set correctlypatient has to do excessive work to trigger a breath, autoPEEP How to identify it:
Pressure-time curve: there will be a huge negative deflection before each pressure curve and/or negative pressure deflections that dont result in a breath delivery Flow-time curve: there will be a blip where the patient attempts to trigger Pressure-volume loop: there will be a large pig tail on the loop

How to fix it: set sensitivity so that minimal effort is required to trigger the ventilator, eliminate the autoPEEP

Setting the Rise Time

The faster the flow valve opens, the faster the set pressure is reached in pressure modes If the valve opens so fast that the flow is instantaneously delivered to the airway, you can get an overshoot in the pressure curve with ringing (Bart Simpson hair)you need to increase the rise time if this occurs this makes the flow valve open a bit more slowly If the valve opens too slow, the pressure curve becomes rounded when it should be square in a pressure modethis will decrease Vt deliveryyou need to decrease the rise time if this occurs

Volume-Targeted Ventilation
(Volume- Targeted Ventilation)
Preset Peak Flow

Controlled Mode

(Volume-Targeted Ventilation)
Flow
(L/min)

Assisted Mode

(L/min)

Flow

Dependent on CL & Raw

Pressure
(cm H2O)

Pressure
(cm H2O)

Preset Vt

Volume Volume (ml) Time (sec)

2000

Volume (ml)
(ml)
Essentials of Ventilator Graphics

Essentials of Ventilator Graphics

RespiMedu

Time (sec)

2000

RespiMedu

(Volume-Targeted Ventilation)
(L/min)

SIMV

(Volume-Targeted Ventilation)
(L/min)

SIMV+PS

Flow

Flow

Pressure
(cm H2O)

Set PS level

Pressure
(cm H2O)

Volume (ml)
(ml)

Volume (ml)
(ml)
Essentials of Ventilator Graphics

Time (sec)
Essentials of Ventilator Graphics
2000

RespiMedu

Time (sec)

2000

RespiMedu

Suggested Websites
www.adhb.govt.nz/newborn/TeachingResources/Ventilat ion/RespiratoryFunctionMonitoringandGraphics.htm www.rtmagazine.com/issues/articles/2002-02_04.asp www.rcsw.org/Download/2006_RCSW_conf/Presentatio n&202006%20RCSW%20Waveforms_in_ARDS%20Dea n%20H.pdf www.aarc.org/education/webcast/archives/waveforms/03 .01.05/ppt#256,1,Using the Ventilator To Probe Physiology: Monitoring Graphics and Lung Mechanics During Mechanical Ventilation www.brighamandwomens.org/respiratorytherapy/advme cven2.ppt