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

clinical

Mechanical ventilator

patient

Waveform

Signal generation

Waveform generation

Role of Ventilator Waveforms in Ventilator-Dependent Patients

1. 2. 3. 4. 5. 6. Identify pathophysiologic process Recognize a real time change in patients condition Optimize ventilator setting and treatment Determine effectiveness of ventilator settings Detect adverse effects of mechanical ventilation Minimize risk of ventilator-induced complications

Respir Care 2005;50(2):246-259

Pressure-Time Curve
Inspiration Expiration

TV
PEEP/CPAP

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 above baseline = expiration

Pressure below baseline = Inspiration

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

Pr

Paw = Pr+Palv+Ppl
Ppl ~ 0

then Paw=Pr+Palv
Palv

Pr=0 :flow =0 then Paw =Palv=Pplat

Ppl

High Pressure Alarm

high pressure alarm
low Pplat High Pplat PEEP application High resistive stage

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 patients 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 patients demand The ideal waveform for pts receiving pressure ventilation is roughly square in shape (Figure B) satisfy the pts 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

12 32

Point of equilibration

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

Quiz #4
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

P-T curve in VCV

Flow-Time Curve
Applications : Waveform shape Type of breathing Presence of Auto-PEEP Patients 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. B. C. D. E. Decrease PIF Increase Vt Increase RR Increase PEEP 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 time

flow

time

Quiz # 7
A. B. C. D. E. Decrease PEEP Decrease RR Increase RR Increase IT 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
In PC Inspired flow not = 0 (underventilation)

time

flow

time

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 sharks 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

Square wave = VCV

Controlled

Assisted

PEEP5

A/CMV (constant flow) + PEEP 5

End inspiratory flow reach baseline

PCV with PEEP 5 cmH2O Pressure preset

PEEP5

Decelerating (Ramp) flow

VCV (decelerating flow) with PEEP Non-Pressure preset

PEEP5

Pressure preset

PEEP 6

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

Which of the following statements concerning the figure is correct?

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 patients 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

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

Which of the following actions should be taken immediately in an attempt to reverse the hypotension? 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

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