ventilator waveform analysis
DESCRIPTION
waveformTRANSCRIPT
Chest Conference
Teerapat Yingchoncharoen M.D.
Department of Internal Medicine PSU
Content
• Pressure-Time Curve
• Flow-Time Curve
• Volume-Time Curve
• Step Approach to waveform analysis
• Combined curve
• Flow-Volume Loop
• Post-test examination
Physician
Mechanical ventilator patient
clinical ?
Waveform
Signal generation
Waveform generation
Role of Ventilator Waveforms in
Ventilator-Dependent Patients
1. Identify pathophysiologic process
2. Recognize a “real time” change in patient’s condition
3. Optimize ventilator setting and treatment
4. Determine effectiveness of ventilator settings
5. Detect adverse effects of mechanical ventilation
6. Minimize risk of ventilator-induced complications
Respir Care 2005;50(2):246-259
Pressure-Time Curve
Inspiration Expiration
PEEP/CPAP
TV
Pressure-Time Curve
Applications :-
• Breath type identification
• Work required to trigger the breath
• Breath timing (inspiration Vs exhalation)
• Adequacy of inspiration
• Adequacy of inspiratory plateau
• Adequacy of inspiratory flow
• Results and adequacy of a static mechanics maneuver
• Adequacy of the Rise Time Setting
Identifying breath type
Five different breath types can be identified
by viewing pressure-time curve :-
1. Ventilator-initiated mandatory breaths
2. Patient-initiated mandatory breaths
3. Spontaneous breaths
4. Pressure support breaths (PSV)
5. Pressure control breaths (PCV)
1. Ventilator-Initiated Mandatory Breaths (Controlled Ventilation)
A pressure rise without a pressure deflection below baseline
2. Patient-Initiated Mandatory Breaths (Assisted Ventilation)
A pressure deflection below baseline
3. Spontaneous breaths
Pressure below baseline = Inspiration
Pressure above baseline = expiration
4. Pressure Support Breaths (PSV)
Ti Ti
4. Pressure Control Breaths (PCV)
Ti Ti
Quiz # 1: What is this mode of ventilation
BiLevel Ventilation With Spontaneous Breathing at PEEPH and PEEPL
Quiz # 2: What is this mode of ventilation
Airway Pressure Release Ventilation (APRV)
Assessing Plateau Pressure
Airway Pressure Ppeak = Pairway + Pplateau
Change in Airway Resistance Change in Compliance
Basic Lung Mechanic
Ppl
Palv
Pr Paw = Pr+Palv+Ppl
Ppl ~ 0
then Paw=Pr+Palv
Pr=0 :flow =0
then Paw =Palv=Pplat
High Pressure Alarm
high pressure alarm
low Pplat
High resistive stage
High Pplat
PEEP application
increase compliance decrease compliance
parenchymal disease pleural disease
High Pressure Alarm
• Resistance load
- bronchospasm
- secretion
- airway disease
- artificial airway
problem
• Compliance load
- parenchymal
injury
- ARDS
- Pneumonia
- Pulmonary edema
- increase pleural
pressure
Quiz # 3: Is this Pplt reliable ?
No !! This is unstable pressure plateau, possibly due to a leak or the patient’s inspiratory effort.
Assessing the work to trigger
PT = Triggering time, DTOT = Delayed time
Assessing rise time
•Rise in target pressure depend on lung impedence and/or patient’s demand •The ideal waveform for pts receiving pressure ventilation is roughly square in shape (Figure B) satisfy the pt’s flow demand while contributing to a higher mean airway pressure. • Figure A = Low compliance or high flow demand • Figure C = High compliance or low flow demand (Overshoot)
Setting Rise Time
Increase rise time Decrease rise time
Assessing Auto-PEEP maneuver
Point of equilibration
12 32
Quiz #4
A 22-year-old patient presented with acute severe asthma
with respiratory failure. He was intubated and mechanically
ventilated. After the initial setting of ventilatory support, the
patient was still discomfort. The pressure-time curve was
shown below. What is the most-likely cause?
Thai Board
A. Too high PEEP level
B. Insufficient inspiratory flow
C. Auto trigger of ventilator
D. Air leak in ventilatory system
E. High tidal volume
Thai Board
Quiz #4
P-T curve in VCV
Flow-Time Curve
Applications :-
• Waveform shape
• Type of breathing
• Presence of Auto-PEEP
• Patient’s response to bronchodilators
• Adequacy of inspiratory time in pressure
control ventilation
• Presence and rate of continuous air leaks
Flow-Time Curve
= PEFR
Actual expiratory time
Total available expiratory time
Verifying Flow Waveform Shape
Detecting the type of breathing
Quiz # 5
A 65-year-old man with COPD had developed dyspnea for
5 days. A volume-controlled respirator was applied with
an FiO2 of 0.6, RR 20/min, Vt of 600 cc and PIF 40 L/min.
ABG was then performed and revealed pH of 7.30,
PaCO2 60 mmHg and PaO2 60 mmHg. The flow-time curve is shown as follows.
Flow
Time
Thai Board
What is the most appropriate next step of
management ?
A. Decrease PIF
B. Increase Vt
C. Increase RR
D. Increase PEEP
E. Increase FiO2
Thai Board
Determining the presence of Auto-PEEP
Effects of Change in Rate
Effects of Change in Flow
Management of Auto-PEEP
• Sedation and paralysis
• Decreasing airway resistance with
medications
• Increasing inspiratory flow rates (ie,
decreasing I:E ratio)
• Applying small amounts of external PEEP
Evaluating Bronchodilators Response
Quiz # 7
A patient with pneumothorax S/P ICD insertion
breathing with PCV Setting = Rate 20/min
PEEP 15 IT 0.8 RR 24-28 FiO2 0.6 TV 300
The waveform showed the following, what would
you do next ?
pressure
flow
time
time
Quiz # 7
A. Decrease PEEP
B. Decrease RR
C. Increase RR
D. Increase IT
E. Decrease IT
Quiz # 7
A patient with pneumothorax S/P ICD insertion
breathing with PCV Setting = Rate 20/min
PEEP 15 IT 0.8 RR 24-28 FiO2 0.6 TV 300
The waveform showed the following, what would
you do next ?
pressure
flow
time
time
In PC Inspired flow not = 0
(underventilation)
Inspiratory time setting in PCV
PCV Changes in Ti
Quiz # 8 : What happened ?
Water in expiratory tube of ventilator circuit
Volume-Time Curve
Applications :-
• Air-trapping detection
• Leaks in the patient circuit detection
Volume-Time Curve
Leak or Air-Trapping
Expiratory volume does not return to baseline
Air-trapping in COPD
Quiz # 9 : What happened ?
Excessive inspired tidal volume
Step-Approach for Waveform Analysis
Analyzing waveform – step 1
• determine the CPAP level
– baseline position from which there is a downward
deflection on, at least, beginning of inspiration, and
to which the airway pressure returns at the end of
expiration
Analyzing waveform – step 2
• is the patient triggering?
– There will be a negative deflection into the CPAP line
just before inspiration
Analyzing waveform – step 3
• what is the shape of the pressure wave?
– If the curve has a flat top, then the breath is pressure
limited, if it has a triangular or shark’s fin top, then it
is not pressure limited and is a volume breath
Analyzing waveform – step 4
• what is the flow pattern?
– If it is constant flow (square shaped) this must be
volume controlled, if decelerating, it can be any mode
Analyzing waveform – step 5
• Is the patient gas trapping?
– expiratory flow does not return to baseline before
inspiration commences (i.e. gas is trapped in the
airways at end-expiration)
Analyzing waveform – step 6
• the patient is triggering – is this a pressure supported or SIMV or VAC breath? – This is easy, the pressure supported breath looks completely
differently than the volume control or synchronized breath: the PS breath has a decelerating flow pattern, and has a flat topped airway pressure wave. The synchronized breath has a triangular shaped pressure wave
Analyzing waveform – step 7
• the patient is triggering – is this pressure support or pressure control? – The fundamental difference between pressure support and
pressure control is the length of the breath – in PC, the ventilator determined this (the inspired time) and all breaths have an equal “i” time. In PS, the patient determined the duration of inspiration, and this varies from breath to breath
Analyzing waveform – step 8
• is the patient synchronizing with the ventilator? – Each time the ventilator is triggered a breath should be
delivered. If the number of triggering episodes is greater than the number of breaths, the patient is asynchronous with the ventilator. Further, if the peak flow rate of the ventilator is inadequate, then the inspiratory flow will be "scooped" inwards, and the patient appears to be fighting the ventilator
Combining the graphics
PEEP5
Assisted
Square wave = VCV
Controlled
A/CMV (constant flow) + PEEP 5
PEEP5
Pressure preset
End inspiratory flow reach baseline
PCV with PEEP 5 cmH2O
PEEP5
Non-Pressure preset
Decelerating (Ramp) flow
VCV (decelerating flow) with PEEP
PEEP 6
Pressure preset
End-inspiratory flow
Not return to baseline
Pressure support with CPAP 6
Negative reflection CPAP
Volume target SIMV
Pressure target SIMV
CPAP with Volume- target SIMV
PCIRV
Flow-Volume Loop
Applications :-
• Inspiratory area calculations
• Work to trigger a breath
• Changes in compliances and resistance
• Lung overdistention
• Adjustments to pressure support
• Inflection points
• Adequacy of peak flow rates
Flow-Volume Loop: Introduction •The calculation of the area of the loop to the left of the volume axis. •An approximation of the work imposed by the ventilator.
PEEP
Breath type
Breath type
Breath type
Assessing the work to trigger
Trigger tail
Assessing the work to trigger
Trigger tail : Too high pressure sensitivity
Assessing compliance
Increased Resistance
Lung overdistention
What happened: “Figure eight”
Insufficient inspiratory flow
Case Pressure-Volume Loop
Post-test exams
A patient is agitated during mechanical ventilation and
interventions are undertaken to achieve better patient-ventilator
synchrony. Flow and pressure curves from before (top panel) and
after (bottom panel) the intervention are shown in Figure 1. Based
on the change shown, which of the following best describes the
intervention?
A. Matching intrinsic PEEP with extrinsic PEEP to facilitate triggering each breath.
B. Increasing flow rate and respiratory rate to accommodate increased respiratory drive.
C. Switching the mode to pressure support. D. Switching the mode to airway pressure release. E. Paralysis.
ACCP-SEEK 2006
Which of the following best describes the
mechanical ventilation mode depicted in Figure 1?
A. Pressure assist-control ventilation
(PACV).
B. Volume assist-control ventilation
(VACV).
C. Pressure support ventilation (PSV).
D. Pressure-targeted synchronized
intermittent mandatory
(SIMV).
E. Continuous positive airway pressure
(CPAP).
ACCP-SEEK 2006
You have been asked to assist in the ventilatory management of
a 70-year-old man with ARDS complicating urosepsis. He
weighs 70 kg, is deeply sedated, and has been paralyzed with a
nondepolarizing agent. Figure 1 shows an airway pressure/lung
volume loop recorded during volume preset mechanical
ventilation with constant inspiratory flow of 0.6 L/s.
ACCP-SEEK 2006
A. Positive end-expiratory pressure (PEEP) should be raised to 18 cm H2O.
B. Some units of the lung are being inflated close to total lung capacity.
C. The deflation compliance of this patient’s lungs is 0.3 L/cm H2O.
D. The area between the inflation and deflation limb reflects lung hysteresis and is determined by recruitment and surface tension phenomena.
E. The vital capacity of this patient is probably <0.5 L.
ACCP-SEEK 2006
Which of the following statements concerning the figure is correct?
A 50-kg, 30-year-old patient with acute, severe asthma is receiving
volume preset ventilation in the assist/control mode. She is
spontaneously breathing with a rate of 30, inspiratory flow rate 60
L/min, tidal volume 0.5 L, FIO2 0.4, and PEEP 0.0. Monitoring of
airflow reveals the profile shown in Figure 1. Pulse is 100 and blood
pressure is 90/60 mm Hg with a pulsus paradoxus of 28 mm Hg.
ACCP-SEEK 2006
A. Pericardiocentesis. B. Placing a chest tube.
C. Withdrawing the endotracheal tube from right mainstem bronchus.
D. Decreasing inspiratory flow rate. E. Sedation and paralysis.
ACCP-SEEK 2006
Which of the following actions should be taken immediately in an attempt to reverse the hypotension?
A patient is receiving volume assist control mechanical
ventilatory support for the acute respiratory distress
syndrome (ARDS). He is heavily sedated and not triggering
ventilator breaths. His ventilator graphics are shown in
Figure 1. Over the last several hours, his peak airway
pressure has slowly risen and finally the high pressure alarm
is activated. A chest radiograph reveals bilateral fluffy
infiltrates. You examine him and determine that significant
pulmonary edema has developed. Which set of graphics in
Figure 2 is most consistent with these changes?
A. Breath A. B. Breath B C. Breath C. D. Breath D. E. Breath E.
ACCP-SEEK 2006