Ventilator Graphics v3.

Charles Williams RRT, AE-C

Learner Objectives

Understand the importance of monitoring and interpreting ventilator graphics. Learn the basic shapes of waveforms. Identify the different types of waveforms and loops available on most ventilators. Learn to use the graphics to identify patient/ventilator problems, and make the appropriate adjustments.

Why do we monitor ventilator graphics and waveforms?

Allows practitioners to evaluate and troubleshoot the patients response to the ventilator. Monitor proper ventilator function. Monitor the patients disease status (Compliance and Airway Resistance). Assess response to therapy. Allow fine tuning of ventilator to decrease WOB, optimize ventilation, and maximize patient comfort.

Ventilator graphics are waveforms that reflect the patient-ventilator system and their interaction.

Learning to analyze and interpret ventilator graphics can be a very useful tool for respiratory therapists. The graphics can assist therapists in making recommendations and necessary adjustments to the ventilator.

Practitioners can use ventilator graphics to assess the condition of a patients lungs in the same way a cardiologist uses the graphics of an EKG to view the condition of the heart.

Puritan Bennett 840

Hamilton Galileo

Drager Evita Respironics Esprit

The graphics display will have different appearances and configurations, depending on the make and model of ventilator.

Basic Shapes of Waveforms

Basic waveforms that plot pressure, flow, or volume against time. Time is on the x-axis. Waveforms that combine pressure or flow, with volume. (P/V or F/V). There is no time component.

Scalars
Time

Loops

Basic Shapes of Waveforms

Generally, The ascending and descending ramps can be considered the same as exponential ramps, So you really only need to remember three shapes: Square, Ramp, and Sine waves.

Basic Shapes of Waveforms

Squares

Squares represent fixed, constant, or set parameters. For example, pressure setting in Pressure Control mode. Ramps represent variables. Will vary with changes in lung characteristics. Ramps can be accelerating or decelerating. Sine waves are seen with spontaneous, unassisted breathing.

Ramps

Sine

Basic Shapes of Waveforms

Question: What are the three basic shapes of waveforms? Answer: Square Ramp Sine

Types of Waveforms
Each time the ventilator delivers a breath, there are waveforms that are displayed on the graphics screen: Pressure, Flow, and Volume.

Types of Waveforms

(20)

The pressure scalar displays the amount of pressure generated with each breath. The scale is located on the left side in cmH20. The peak pressure of these breaths are about 22 cmH20.

Types of Waveforms

The flow scalar displays the flowrate, or speed associated with each breath. In this example, the breath begins at a fast flowrate and then decreases during inspiration.

Types of Waveforms

(375 ml)

(250 ml)

Volume in

Volume out

The volume scalar displays the amount of volume inhaled and exhaled with each breath. The scale is located on the left side in mls. These breaths are about 370 ml.

Types of Waveforms
Question:
What 3 waveforms are displayed on the graphics screen? Answer:
Pressure

Flow
Volume

Types of Waveforms
Volume Modes
Pressure Pressure

Pressure Modes

square

Flow

Flow

square

Volume

Volume

Volume Control SIMV (Vol. Control)

Pressure Control *PRVC SIMV (PRVC) SIMV (Press. Control)

Pressure Support *Volume Support

* Considered a dual-mode of ventilation

Types of Waveforms
Volume Modes Pressure Modes

Pressure

Pressure

Flow

Flow

Note: Some ventilators allow you select the desired flow pattern for different modes.

Types of Waveforms
SIMV (Vol. Control) + Pressure Support

Volume Breath

Pressure Breath

Pressure Breath

Volume Breath

For combination modes, such as SIMV/PS, the graphics can show both volume breaths and pressure breaths.

Pressure Waveform
Volume Modes
Pressure Pressure

Pressure Modes

square

Flow

Flow

square

Volume

Volume

Volume Control SIMV (Vol. Control)

Pressure Control PRVC SIMV (PRVC) SIMV (Press. Control)

Pressure Support Volume Support

Pressure Waveform
The pressure waveform can be used to assess:
Breath Type (Pressure vs. Volume) Air trapping (auto-PEEP) Airway Obstruction Bronchodilator Response Respiratory Mechanics (Compliance/Raw) Active Exhalation PIP, Pplat CPAP, PEEP Asynchrony Triggering Effort

Pressure Waveform
Volume Modes Pressure Modes

If the ventilator delivers a volume breath, the shape of the pressure waveform will be a ramp.

If the ventilator delivers a pressure breath, the shape of the pressure waveform will have a square shape.

square

Ramp = variable

Square = constant

Pressure Waveform
Volume Modes Pressure Modes

This means that pressure will vary, depending on lung characteristics; (compliance, airway resistance, etc.)

This means that pressure will remain the same during inspiration.

Ramp = variable

Square = constant

Pressure Waveform
Pressure waveform Pressure waveform with inspiratory pause
PIP Pplat Raw

Setting an inspiratory pause time or performing an insp. hold maneuver, will create a plateau on the waveform. The plateau allows for easy visualization of PIP, Pplat, and Raw. Adding an inspiratory pause time may improve distribution of ventilation.

Pressure Waveform
I-time Peak Inspiratory Pressure (PIP) Plateau Pressure (Pplat) Alveolar Distending Pressure
Elastic Recoil Pressure

= Mean Airway Pressure (MAP)

Pressure Waveform

10 5

PEEP
No patient effort

PEEP
Patient triggered breath

PEEP

The baseline for the pressure waveform will be higher, when Positive EndExpiratory Pressure (PEEP), is added. PEEP is also a component of mean airway pressure (MAP). With patient triggered breaths, there will be a negative deflection just before the waveform.

Pressure Waveform
Peak Inspiratory Pressure (PIP)

I-time

Pressure Waveform
Increased Airway Resistance (Raw)
PIP
(Increased Raw) Pplat

Decreased Compliance
PIP
(Normal Raw) Pplat

Increased airway resistance (Raw) will cause the PIP to increase. The Pplat pressure remains normal.
Decreased lung compliance will cause the entire waveform to increase in size. The difference between PIP and Pplat will remain normal.

Pressure Waveform
Air-Trapping (auto-PEEP)

Expiratory hold maneuver

auto-PEEP (trapped air) PEEP
auto-PEEP
Set PEEP

PEEP

+9 +5 +14

Total-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
Label the parts:
A
B C =G

A= Inspiratory Time B= Peak Insp. Pressure (PIP) C= Plateau Pressure (Pplat)

D= Airway Resistance (Raw) E= Alveolar Distending Pressure F= Elastic Recoil Pressure

G= Mean Airway Pressure (MAP)

Pressure Waveform
Question: What does this pressure waveform show?

Answer: Increased airway resistance

Flow Waveform
Volume Modes
Pressure Pressure

Pressure Modes

square

Flow

Flow

square

Volume

Volume

Volume Control SIMV (Vol. Control)

Pressure Control PRVC SIMV (PRVC) SIMV (Press. Control)

Pressure Support Volume Support

Flow Waveform
If a volume breath is delivered, the shape of the waveform will be a square. This means that the flowrate stays the same during inspiration. If a pressure breath is delivered, the shape of the waveform will be a ramp. This means that the flowrate starts out high and then decreases during inspiration.

Square = constant

Ramp = variable

Flow Waveform
The flow waveform can be used to assess:
Air trapping (auto-PEEP) Airway Obstruction I-Time adjustment Bronchodilator Response Active Exhalation Breath Type (Pressure vs. Volume) Inspiratory Flow Asynchrony Triggering Effort

Flow Waveform
Volume Modes Pressure Modes

I-time
Set Flowrate

I-time
PIF

E-time

E-time

PEF

PEF

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
Airway Obstruction
PIF

Inspiratory flow takes longer to return to baseline

= Normal
PEF

In patients with severe airway obstruction, the flow waveform can become a plateau. This can become a problem in flow-cycled modes, such as Pressure Support. (asynchrony, W.O.B.)

Flow Waveform
Auto-Peep (air trapping)

Expiratory flow does not return to baseline

= Normal

Start of next breath

If the expiratory portion of the waveform doesnt return to baseline before the start of the next breath starts, there could be air trapping. (emphysema, improperly set I:E ratio).

Flow Waveform
Bronchodilator Response
Pre-Bronchodilator I-time Post-Bronchodilator

Prolonged E-time

Normal E-time

Reduced PEF Improved PEF

To assess response to bronchodilator therapy, you should see an increase in peak expiratory flow rate. Also, the expiratory portion of the curve should return to baseline sooner.

Pressure Control, PRVC

(Time-cycled)

Flow Waveform
Adjusting I-Time
Pressure Support, Volume Support
(Flow-cycled)

Pressure

Flow

Inspiration should end when flow reaches baseline

Inspiration ends before flow reaches baseline

Volume

In Pressure modes that are time-cycled (Pressure Control), the flow waveform should return to baseline. In Pressure modes that are flow-cycled (Pressure Support), the flow waveform does not return to baseline. (Adjustment is made with Insp. Cycle Off %)

Flow Waveform
Adjusting I-Time
I-time
(Too short)

I-time
(Too long)

Not here

Inspiration should end here

Inspiration should end here

Not here

Remember, this applies to Control modes with a decelerating flow (ramp). This includes Pressure Control, PRVC, SIMV (Press. Control), and SIMV (PRVC). Volume Control and SIMV (Vol. Control) have a constant flow.

Flow Waveform
Question: What does this flow pattern show?

Answer: Air trapping (auto-PEEP)

Flow Waveform
Question: To assess improvement after a breathing treatment you should see what?
Pre-Bronchodilator I-time Post-Bronchodilator

Normal E-time

Improved PEF

Answer: Improved PEF and shorter E-time

Volume Waveform
Volume Modes
Pressure Pressure

Pressure Modes

square

Flow

Flow

square

Volume

Volume

Volume Control SIMV (Vol. Control)

Pressure Control PRVC SIMV (PRVC) SIMV (Press. Control)

Pressure Support Volume Support

Volume Waveform
Volume Modes Pressure Modes

The Volume waveform will generally have a mountain peak shape regardless of what mode, of ventilation.

There may also be a small plateau at the top of the volume waveform

Volume Waveform
The volume waveform can be used to assess:
Tidal Volume Active Exhalation Asynchrony Airway Resistance Air trapping (auto-PEEP) Leaks

Volume Waveform

Inspiratory Tidal Volume Exhaled volume should return to baseline

Volume Waveform
Air-Trapping or Leak

Volume Loss

If the exhalation side of the waveform doesnt return to baseline, it could be from air-trapping (improperly set I-time, emphysema), or there could be a leak (ET tube, vent circuit, chest tube, etc.)

Volume Waveform
Increased Airway Resistance
= Normal

Exhaled volume taking longer to get out

If there is an increase in airway resistance, it will take longer for the exhaled volume to return to baseline. This is more commonly seen with a damp or blocked expiratory filter/valve.

Volume Waveform
Question: The volume waveform is most commonly used to assess which two situations?

Answer: Air trapping and leaks

Is it Volume or Pressure?
Volume Modes Pressure Modes

Pressure

Pressure

square

Flow

square

Flow

Volume

Volume

Here is an easy way to tell what type of mode (or type of breath) this is, just by looking at the graphics. Look at the pressure waveform and remember the letter P. With Pressure breathsThe Pressure waveformwill have a Plateau.

Is it Volume or Pressure?
The pressure waveform has a plateau

The flow waveform doesn't return to baseline

Is it a Volume or Pressure mode? (Hint: look at the pressure waveform) Is it a Control mode or Support mode? (Hint: look at the flow waveform)

Volume Modes

Pressure Modes

Ventilator Graphics

PressureVolume 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 theres 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

The Pressure/Volume Loop can be used to assess: Lung Overdistention Airway Obstruction Bronchodilator Response Respiratory Mechanics (C/Raw) Flow Starvation Leaks WOB Triggering Effort

Pressure-Volume Loops

Volume Modes

Pressure Modes

In Volume modes, the P/V loop will normally have a football shape.

In Pressure modes, the P/V loop will have a square appearance.

Pressure-Volume Loops

500

Dynamic Compliance (Cdyn)

250

10

15

20

If PEEP is added, the loop will begin at the set PEEP level. The top part of the P/V loop represents Dynamic compliance (Cdyn). Cdyn = volume/pressure

Pressure-Volume Loops

500

Plateau

250

10

20

Pressure modes deliver a set constant pressure during inspiration, creating a plateau on the pressure waveform. This will also create a plateau on the P/V loop.

Pressure-Volume Loops
Overdistention
500

beaking

250

10

20

Pressure continues to increase with little or no change in volume, creating a bird beak. Fix by reducing amount of tidal volume delivered.

Pressure-Volume Loops
Triggering Effort

WOB

tail

If the patient is triggering the breath, you will see a crossover or tail, at the beginning of the loop. As WOB increases, the tail will become larger.

Pressure-Volume Loops
Airway Resistance
500

Increased expiratory resistance:

secretions, bronchospasm, etc.
250

Increased inspiratory resistance:

10 20

ETT size too small, tube kinked, patient biting tube, etc.

As airway resistance increases, the loop will become wider. An increase in expiratory resistance is more commonly seen.

Pressure-Volume Loops

Increased Compliance
Cdyn
500

Decreased Compliance

500

Cdyn
250 250

10

20

10

20

Cdyn = Dynamic Compliance Examples: Examples: (volume/pressure) Emphysema, ARDS, CHF, Post Surfactant Therapy Atelectasis, Pleural Effusions

Pressure-Volume Loops

Increased Compliance
600 600/12 Cdyn = 50 ml/cmH20

Decreased Compliance

500

500

Increased volume

300

300/22 Cdyn = 14 ml/cmH20

250
Decreased volume

250

12 Decreased pressure

22

10

20

10

Increased pressure

20

VT (Tubing compliance) Examples: Examples: Cdyn = PIP - PEEP Emphysema, ARDS, CHF, Post Surfactant Therapy Atelectasis, Pleural Effusions

Pressure-Volume Loops
A Leak
500

250

10

20

The expiratory portion of the loop does not return back to baseline. This indicates that there is a leak.

Pressure-Volume Loops
point of alveolar collapse
500

Upper Inflection Point

Third Inflection Point

250

Lower Inflection Point

10 20

point of alveolar opening

Inflection Points
Some lung protection strategies for treating ARDS, suggest setting PEEP just above the lower inflection point, to hold the alveoli open.

Pressure-Volume Loops

500

250

10

20

Question: What does this loop show? Answer: Decreased lung compliance. (ARDS, CHF, Atelectasis)

Pressure-Volume Loops

500

250

15

30

Question: What is happening when there is a bird beak appearance on the P/V loop? Answer: Lung overdistention. Pressure continues to increase, with no increase in volume.

Pressure-Volume Loops

Question: What does this P/V loop show? Answer: Increased expiratory airway resistance (Raw).

Ventilator Graphics
40 20 200 0 20 600

FlowVolume Loops

40

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
The Flow/Volume Loop can be used to assess: Air trapping Airway Obstruction Airway Resistance Bronchodilator Response Insp/Exp Flow Leaks Water or Secretion accumulation Flow Starvation Asynchrony

Flow-Volume Loops
60 40

20

Begin Inspiration
200 400 600

Begin Expiration

-20

-40

-60

Peak Expiratory Flow (PEF)

Flow-Volume Loops
Constant Flow Variable Flow

The shape of the inspiratory portion of the curve will match the flow waveform.

Flow-Volume Loops
PEF

Airway Obstruction
Reduced PEF
scooping

PFT view

With conditions that cause airway obstruction (asthma), you will see a lower peak expiratory flow (PEF). You should also see scooping on the expiratory portion of the loop. *Scooping means that the volume is being exhaled at a slower rate because of obstruction.

Flow-Volume Loops
Airway Obstruction

Ventilator graphic view

scooping

Reduced Peak Flow (PEF)

The F-V loop appears upside down on most ventilators.

Flow-Volume Loops
60

Air Trapping or Leaks

40 20

0 200 400 600

-20

loss of volume
-40

= Normal
-60

If there is air-trapping, or a leak, the loop will not meet at the starting point where inhalation starts and exhalation ends.

Flow-Volume Loops
Water or Secretions

If there is a collection of water in the ventilator circuit or a build up of secretions, you will see a jagged, sawtoothed pattern.

Flow-Volume Loops

20

Begin Inspiration
200 400 600

Begin Expiration

-60

Peak Expiratory Flow (PEF)

What points on this F/V loop do the arrows indicate?

Flow-Volume Loops
60 40

20

0 200 400 600

-20

-40

-60

Question: What does this F/V loop show? Answer: There is air-trapping or a leak. (ETT cuff, vent circuit)

Flow-Volume Loops

Question: What is the term used to describe the part of the loop indicated by the arrow? What causes it? Answer: This is known as scooping. Its caused by small airway obstruction.

Asynchrony
(out of sync)

Flow Starvation

The inspiratory portion of the pressure waveform shows a dip. Because of an inadequate flowrate , the patient is sucking in attempting to get more air. This causes a drop in pressure. A main disadvantage of constant flow modes (e.g. Volume Control), is that it may not meet the patients inspiratory demands.

Asynchrony
(out of sync)
Dip

Flow Starvation
Ventilator detects inadequate flow

Some ventilators have an adaptive flow system that will automatically increase flow to try and meet the patients demand. Notice that on the next breath, the flowrate has been increased.

Asynchrony
(out of sync)

F/V Loop

P/V Loop

Any dips or irregular shaped loops are an indication of asynchrony.

Air-Trapping (auto-PEEP)
Causes:
Insufficient expiratory time Early collapse of unstable alveoli/airways during exhalation

How to Identify it on the graphics:

Pressure waveform: While performing an expiratory hold, the waveform rises above baseline. Flow waveform: The expiratory flow wave doesnt return to baseline before the next breath begins. Volume waveform: The expiratory portion doesnt return to baseline. Flow/Volume Loop: The loop doesnt return completely to baseline Pressure/Volume Loop: The loop doesnt return completely to baseline

How to Fix:
Give a bronchodilator treatment, adjust I-time, increase flow, adjust PEEP.

Airway Resistance Changes

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

How to identify it on the graphics:

Pressure waveform: PIP increases, but the plateau stays the same Flow waveform: It takes longer for the exp side to reach baseline Volume waveform: It takes longer for the exp curve to reach the baseline Pressure/Volume loop: The loop will be wider. Increased insp. resistance will cause it to bulge to the right. Increased exp resistance will cause it to bulge to the left. Flow/Volume loop: decreased exp flow, scooping on the exp curve

How to fix:
Give a bronchodilator treatment, suction patient, drain water, change HME, change ETT, add a bite block, reduce flowrate, change exp filter.

Compliance Changes
Decreased compliance
Causes
ARDS Atelectasis Abdominal distension CHF Consolidation Fibrosis Overdistention Pneumothorax Pleural effusion

Increased compliance
Causes
Emphysema Surfactant Therapy

How to identify it on the graphics:

Pressure wave: PIP and plateau both increase Pressure/Volume loop: lays more horizontal

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 identify it on the graphics:

Volume waveform: Expiratory side of wave doesnt return to baseline Flow waveform: PEF decreased Pressure/Volume loop: Exp side doesnt return to the baseline Flow/Volume loop: Exp side doesnt 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 Pressure waveform: Patient tries to inhale/exhale in the middle of the waveform, causing a dip in the pressure Flow waveform: 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 on either inspiratory or expiratory side. Flow/Volume loop: Patient makes effort to breath causing dips in loop on either inspiratory or expiratory side.

How to identify it on the graphics:

How to fix it:

Try increasing the flow rate, decreasing the I-time, or increasing the set rate to capture the patient to better meet the patients needs. Change the mode - sometimes changing from partial to full support will solve the problem. If neurological, may need paralytic or sedative. Adjust sensitivity

The pressure waveform does have a plateau, but its from an insp. hold or set insp. pause.

square

Is this a Volume or Pressure mode?

Ventilator Graphics

Adjusting Rise time & Insp. Cycle Off %

Rise Time

Rise Time

The inspiratory rise time is the time it takes to reach full inspiratory flow, or pressure, at the start of each breath. The rise time can be expressed as a percentage of the breath cycle time (%) or in seconds (s).

Rise Time
The Bart Simpson spike
Rise time overshoots desired pressure

Too fast

If rise time is set 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 more slowly.

Rise Time

1. Here we can see the spike on our

graphics.

2. The rise time is set at .05 seconds

Rise Time

3. When we increase the rise time, thus

making it slower

4. the waveform will return to

normal.

Rise Time

Too slow

If rise time is too slow, the pressure waveform will become more slanted, when it should look more square. This may affect Vt delivery and may not meet the patients inspiratory demands. If this occurs, you will need to decrease the rise time to open the valve faster.

Inspiratory Cycle off %

(Flow Cycling)

In flow-cycled modes, like Pressure Support & Volume Support, the inspiratory cycle off % determines when the ventilator cycles from inspiration to expiration. Also know as: Inspiratory cycle threshold Inspiratory flow termination, Expiratory flow sensitivity, Inspiratory flow cycle %, E-cycle, etc

Inspiratory Cycle off %

(Flow Cycling)

pressure

Inspiration ends

flow

The inspiration ends when inspiratory flow has dropped to a specific flow value.

Inspiratory Cycle off %

(Flow Cycling)
Peak Inspiratory Flow (PIF)
100%
75%

Flow

50% 25%

30%

In the above example, the ventilator is set to stop inspiration and begin expiration, at 30% of the patients peak inspiratory flow (PIF).

Inspiratory Cycle off %

(Flow Cycling)

The ventilator will cycle off inspiration at this point

and then begin expiration

Inspiratory Cycle off %

(Flow Cycling) Exhalation spike

100%

100%

60% 10%

The cycle off percentage is too high (60%), cycling inspiration off too soon.
This makes the breath too small. (not enough Vt.)

The cycle off percentage is too low (10%), This makes the breath too long. This forces the patient to actively exhale against the breath, creating a pressure spike. (increases WOB),

Rise Time
Question: What does this waveform show?

Answer: Rise time is too slow

Inspiratory Cycle off %

(Flow Cycling)

Question: This pressure support breath is set to insp. cycle off at 80%, 50%, 30%, or 10%?
100% 75%

Flow

50% 25%

Answer: 30%

Sources:
Rapid Interpretation of Ventilator Waveforms,
Waugh, Harwood, and Deshpande

Ventilator Waveform Analysis, Anatomy of Servo-i Graphics, Maquet, inc. Golden Moments in Mechanical Ventilation,
Pearson

Maquet, inc.

Ventilator Graphics

Me using the flow waveform to adjust I-time

Thank You!