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BASIC PRINCIPLES OF MECHANICAL

VENTILATION ANDVENTILATOR GRAPHICS


BASIC PRINCIPLES OF MECHANICAL VENTILATION
Regardless of the disease states when a patient fails to
ventilate or oxygenate adequately the problem lies in 1 of
6 pathophysiological factors
1. Increased airway resistance
2. Change in lung compliance
3. Hypoventilation
4. V/Q mismatch
5. Intrapulmonary shunting
6. Diffusion defects

AIRWAY RESISTANCE
Normal airway resistance in term newborn is 20-40cm
H2O/l/sec
Normal airway resistance in adults is 0.6-cm of H2O /l/sec
Resistance increases by following
1. Inside the airway retained secretions
2. In the wall swelling or neoplasm
3. Outside the wall eg. tumor
Simplified Poiseuilles Law P=V/ r4
P= driving force V=airflow , r=radius of airway
CONDITIONS LEADING TO AIRWAY RESISTANCE
Emphysema
Asthma
Bronchiectasis
Postintubation obstruction
Foreign body
Endotracheal tube (small size and long)
Condensation in vent circuit
ALTB
Bronchiolitis
Epiglottitis
AIRWAY RESISTANCE AND WORK OF BREATHING
Airway resistance ( Raw) is P/ V
P=peak airway pressure-plateau pressure
V=flow
Increase in airway resistance means increase in work
of breathing (i.e. pressure change)
Hypoventilation may result if patient is unable to
overcome the resistance by increasing the work of
breathing
It leads to ventilatory and oxgenation failure


VENTILATORY FAILURE is failure of lungs to
eliminate CO2
OXGENATION FAILURE is failure of lung and heart to
provide adequate oxygen for metabolic needs

LUNG COMPLIANCE
Compliance is lung expansion (volume change) per unit pressure
change(work of breathing) V/ P
Abnormal high or low compliance impairs the patient ability to
maintain effective gas exchange
STATIC COMPLIANCE is measured when there is no airflow(using
plateau pressure PEEP
STATIC COMPLIANCE = tidal volume /plateau pressure- PEEP
DYNAMIC COMPLIANCE is measured when airflow is present(using
the peak airway pressure- PEEP)
DYNAMIC COMPLIANCE = tidal volume / peak airway pressure- PEEP
Normal range of compliance in newborn is 1.5-2 ml/cmH2O/kg
Normal range of compliance in adults dynamic= 30-40 ml/cmH2O
Normal range of compliance in adults static= 40-60 ml/cmH2O


LUNG COMPLIANCE CONT-
Static compliance reflects the elastic properties (elastic
resistance) of lung and chest wall
Dynamic compliance reflects the airway
(nonelastic)resistance and the elastic properties
(elastic resistance) of lung and chest wall
Conditions causing change in static compliance invoke
similar changes in dynamic compliance
Where airway resistance is the only abnormality
dynamic compliance change independently

CLINICAL CONDITIONS THAT DECREASE THE
COMPLIANCE
TYPE OF COMPLIANC
1. STATIC





1. DYNAMIC
CONDITIONS
1. ATELECTASIS
2. ARDS
3. Pneumothorax
4. Obesity
5. Retained secretions


1. Bronchospasm
2. Kinking of ET tube
3. Airway obstruction
HIGH COMPLIANCE
Emphysema
Surfactant therapy

VENTILATORY FAILURE
5 mechanisms lead to ventilatory failure
1. Hypoventilation
2. Persistent ventilation perfusion mismatch
3. Persistent intrapulmonary shunting
4. Diffusion defect
5. Reduction in PIO2 i.e. inspired oxygen tension
HYPOVENTILATION
Caused by depression in CNS
Neuromuscular disease
Airway obstruction
In a clinical setting hypoventilation is characterised by
a reductionof alveolar ventilation and increase in
arterial CO2 tension

VENTIATION PERFUSION MISMATCH
Disease process which causes obstruction or atelectasis
result in less oxygen being available leading to low V/Q
Pulmonary embolism is an example that decreases
pulmonary perfusion and high V/Q
T/T in mechanical ventilation include increasing rate ,
tidal volume , FiO2
T/t directing towards removing obstruction,recruiting
atelectatic zones and preventing closure


INTRAPULMONARY SHUNTING
Causes refractory hypoxia
normal shunt is less than 10%
10-20%mild shunt
20-30% significant shunt
>30% critical and severe shunt
eg pneumonia and ARDS
Classic Qs/Qt=( CcO2-CaO2)/(CcO2-CvO2)

DIFFUSION DEFECT
TYPE
1. Decrease in pressure
gradient


2. Thickening of A-C
membrane

3. Decrease surface
areaof A-C membrane

4. Insufficient time of
diffusion
CLINICAL CONDITIONS
1. High altitude, fire
combustion


2. Pulmonary edema and
retained secretions

3. Emphysema ,
pulmonary fibrosis

4. tachycardia


Purpose of Graphics
Graphics are waveforms that reflect the patient-
ventilator system and their interaction.

Purpose of monitoring graphics includes:
Allows user to interpret, evaluate, and troubleshoot
the ventilator and the patients response to ventilator.
Monitors the patients disease status (C and Raw).
Assesses patients response to therapy.
Monitors ventilator function
Allows fine tuning of ventilator to decrease WOB,
optimize ventilation, and maximize patient comfort.

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:
Square: AKA rectangular or constant wave
Ascending Ramp: AKA accelerating ramp
Descending Ramp: AKA decelerating ramp
Sinusoidal: AKA sine wave
Exponential rising
Exponential decaying
Generally, the ascending/descending ramps are considered the same as the exponential
ramps.
Types of Waveforms
Pressure waveforms
Square (constant)
Exponential rise
Sinusoidal

Flow waveforms
Descending ramp
Square (constant)
Exponential decay
Sinusoidal
Ascending ramp

Volume waveforms
Ascending ramp
Sinusoidal

Sinusoidal waves are seen with spontaneous, unsupported breathing.
Types of Waveforms
Volume Modes Pressure Modes
Volume Control/ SIMV (Vol. Control) Pressure Control/ PRVC
SIMV (PRVC)
SIMV (Press. Control)
Pressure Support/
Volume Support
P
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P
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Pressure/Time Scalar
In Volume modes,
the shape will be
an exponential
rise or an
accelerating ramp
for mandatory
breaths.


In Pressure modes, the
shape will be rectangular or
square.
This means that pressure
remains constant
throughout the breath
cycle.
In Volume modes, adding an inspiratory pause may improve distribution of ventilation.
Pressure/Time Scalar
Air trapping (auto-PEEP)
Airway Obstruction
Bronchodilator Response
Respiratory Mechanics (C/Raw)
Active Exhalation
Breath Type (Pressure vs. Volume)
PIP, Pplat
CPAP, PEEP
Asynchrony
Triggering Effort
Can be used to assess:
Pressure/Time Scalar
The baseline for the pressure waveform increases when PEEP is added.
There will be a negative deflection just before the waveform with patient
triggered breaths.
5
15
No patient effort Patient effort
PEEP +5
Pressure/Time Scalar

A
B
1
2
Inspiratory pause
= MAP

1 = Peak Inspiratory Pressure (PIP)
2 = Plateau Pressure (Pplat)
A = Airway Resistance (Raw)
B = Alveolar Distending Pressure


The area under the entire curve represents the mean airway pressure (MAP).
Pressure/Time Scalar
Increased Airway Resistance Decreased Compliance
PIP
Pplat
PIP
Pplat
A. B.
A-An increase in airway resistance causes the PIP to increase, but Pplat pressure remains
normal.
B-A decrease in lung compliance causes the entire waveform to increase in size.
The difference between PIP and Pplat remain normal.
Volume/Time Scalar
The Volume waveform will generally have a mountain
peak appearance at the top. It may also have a plateau, or
flattened area at the peak of the waveform.

There will also be a plateau if an inspiratory pause set or inspiratory hold maneuver is
applied to the breath.
Volume/Time Scalar
Air trapping (auto-PEEP)
Leaks

Tidal Volume
Active Exhalation
Asynchrony




Can be used to assess:
Volume/Time Scalar
Inspiratory Tidal Volume
Exhaled volume returns
to baseline
Volume/Time Scalar
Air-Trapping or Leak
If the exhalation side of the waveform doesnt return to baseline, it could be from
air-trapping or there could be a leak (ETT, vent circuit, chest tube, etc.)
Loss of volume
Flow/Time Scalar
In Volume modes, the
shape of the waveform will
be square or rectangular.
This means that flow
remains constant
throughout the breath
cycle.




In Pressure modes,
(PC, PS, PRVC,
VS) the shape of
the waveform will
have a decelerating
ramp flow pattern.

Flow/Time Scalar
Air trapping (auto-PEEP)
Airway Obstruction
Bronchodilator Response
Active Exhalation
Breath Type (Pressure vs. Volume)
Flow Waveform Shape
Inspiratory Flow
Asynchrony
Triggering Effort



Can be used to assess:
Flow/Time Scalar
Volume
Pressure
Flow/Time Scalar
The decelerating flow pattern may be preferred over the constant flow pattern. The same
tidal volume is delivered, but with a lower peak pressure.
Flow/Time Scalar
Auto-Peep (air trapping)
If expiratory flow doesnt return to baseline before the next breath starts, theres auto-
PEEP (air trapping) present , e.g. emphysema.
Start of next breath
Expiratory flow
doesnt return to
baseline


= Normal
Flow/Time Scalar
Bronchodilator Response
To assess response to bronchodilator therapy, you should see an increase in peak
expiratory flow rate.

The expiratory curve should return to baseline sooner.
Peak Exp. Flow
Improved Peak Exp. Flow
Shorter
E-time
Longer
E-time
Pre-Bronchodilator Post-Bronchodilator
Types of Waveforms
Volume Modes Pressure Modes
In Pressure Limited, Time-cycled (control) modes, inspiratory flow should return to baseline.
In Flow-cycled (support) modes , flow does not return to baseline.

Volume Control/ SIMV (Vol. control) Pressure Control/ PRVC
SIMV (PRVC)
SIMV (Press. control)
Pressure Support/
Volume Support
P
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P
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Notice the area of no flow indicated by the red line. This is known as a zero-flow state.
This indicates that I-time is too long for this patient.
Types of Waveforms
15 30 5
250
500
Pressure/Volume 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
Lung Overdistention
Airway Obstruction
Bronchodilator Response
Respiratory Mechanics (C/Raw)
WOB
Flow Starvation
Leaks
Triggering Effort



Can be used to assess:
15 30 5
Dynamic
Compliance
A
A = Inspiratory
Resistance/
Resistive WOB
B
Pressure/Volume Loops
(Cdyn)
The top part of the P/V loop represents Dynamic compliance (Cdyn).
Cdyn = volume/pressure
500
250
B = Exp.
Resistance/
Elastic WOB
Pressure/Volume Loops
15 30 5
Overdistention
beaking
Pressure continues to rise with little or no change in volume, creating a bird beak.
Fix by reducing amount of tidal volume delivered
500
250
Pressure/Volume Loops
15 30 5
Airway Resistance
As airway resistance increases, the loop will become wider.
An increase in expiratory resistance is more commonly seen. Increased inspiratory
resistance is usually from a kinked ETT or patient biting.
500
250
15 30 5
250
500
15 30 5
Pressure/Volume Loops
Increased Compliance Decreased Compliance
Example: Emphysema,
Surfactant Therapy
Example: ARDS, CHF,
Atelectasis
500
250
15 30 5
Pressure/Volume Loops
A Leak
The expiratory portion of the loop doesnt return to baseline. This indicates a leak.
500
250
15 30 5
Pressure/Volume Loops
Lower
Inflection Point
The lower inflection point represents the point of alveolar opening (recruitment).
Some lung protection strategies for treating ARDS, suggest setting PEEP just above the
lower inflection point.
Inflection Points
250
500
Point of upper inflection (Ipu)
C lt changed later during
Vt because of
overinflation of the alveoli
The reduction in Clt late in
inspiratory cycle is called
Ipu
The appearance of upper
shape PAO curve indicating
the presence of Ipu is
known as duck bill PVC
Flow/Volume Loops
0
200 400 600
20
40
60
-20
-40
-60
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 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
Flow/Volume Loops
Air trapping
Airway Obstruction
Airway Resistance
Bronchodilator Response
Insp/Exp Flow
Flow Starvation
Leaks
Water or Secretion accumulation
Asynchrony
Can be used to assess:
Flow/Volume Loops
0
200 400 600
20
40
60
-20
-40
-60
PEF
Start of
Inspiration
Start of
Expiration
0
0
Flow/Volume Loops

The shape of the inspiratory curve will match the flow setting on the ventilator.

DIFFERENT FLOW VOLUME LOOPS
A, normal loop
B ski-slop observerved in exp. Flow
limitation
C Extrathoracic airway obstruction
with inspiratory and expiratory air
flow limitation seen in subglotic
stenosis and narrow endotracheal
tube
D Intrathoracic inspiratory airflow
limitationas seen with babies with
intraluminal obstruction
E unstable airway eg tracheomalacia
F Erratic airflow in secretions


Flow/Volume Loops
0
200 400 600
20
40
60
-20
-40
-60
Expiratory
portion of loop
does not
return to starting
point, indicating
a leak.
A Leak
If there is a leak, the loop will not meet at the starting point where inhalation starts and
exhalation ends. It can also occur with air-trapping.

= Normal
0
0
Reduced
PEF
scooping
Flow/Volume Loops
The F-V loop appears upside down on most ventilators.

The expiratory curve scoops with diseases with small airway obstruction (high expiratory
resistance). e.g. asthma, emphysema.

Airway Obstruction
Air Trapping (auto-PEEP)
Causes:
Insufficient expiratory time
Early collapse of unstable alveoli/airways during exhalation
How to Identify it on the graphics
Pressure wave: while performing an expiratory hold, the waveform rises
above baseline.
Flow wave: the expiratory flow doesnt return to baseline before the next
breath begins.
Volume wave: the expiratory portion doesnt return to baseline.
Flow/Volume Loop: the loop doesnt meet at the baseline
Pressure/Volume Loop: the loop doesnt meet at the baseline

Airway Resistance Changes
Causes:
Bronchospasm
ETT problems (too small, kinked, obstructed, patient biting)
High flow rate
Secretion build-up
Damp or blocked expiratory valve/filter
Water in the HME
How to Identify it on the graphics
Pressure wave: PIP increases, but the plateau stays the same
Flow wave: it takes longer for the exp side to reach baseline/exp flow rate is
reduced
Volume wave: it takes longer for the exp curve to reach the baseline
Pressure/Volume loop: the loop will be wider. Increase Insp. Resistance
will cause it to bulge to the right. Exp resistance, bulges to the left.
Flow/Volume loop: decreased exp flow with a scoop in the exp curve
How to fix
Give a treatment, suction patient, drain water, change HME, change ETT,
add a bite block, reduce PF rate, change exp filter.

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

How to Identify it on the graphics
Pressure wave: PIP and plateau
both increase
Pressure/Volume loop: lays
more horizontal
Increased compliance
Causes
Emphysema
Surfactant Therapy








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 ID it
Pressure wave: Decreased PIP
Volume wave: Expiratory side of wave doesnt return to baseline
Flow wave: 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
How to ID it
Pressure wave: patient tries to inhale/exhale in the middle of the waveform, causing
a dip in the pressure
Flow wave: 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 in loop either
Insp/Exp.
Flow/Volume loop: patient makes effort to breath causing dips in loop either
Insp/Exp.
How to fix it:
Try increasing the flow rate, decreasing the I-time, or increasing the set rate to
capture the patient.
Change the mode - sometimes changing from partial to full support will solve the
problem
If neurological, may need paralytic or sedative
Adjust sensitivity

Asynchrony
Flow Starvation
The inspiratory portion of the pressure wave shows a scooping or dip, due to inadequate
flow.
Asynchrony
F/V Loop P/V Loop
Rise Time &
Inspiratory Cycle Off %
Rise Time
The inspiratory rise time determines the amount of time
it takes to reach the desired airway pressure or peak flow
rate.
Used to assess if ventilator is meeting patients demand in Pressure Support mode.
In SIMV, rise time becomes a % of the breath cycle.
Rise Time

If rise time is 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 a bit more slowly.
If rise time is too slow, the pressure wave becomes rounded or slanted,
when it should be more square. This will decrease 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.
too slow too fast
pressure spike
Inspiratory Cycle Off
The inspiratory cycle off determines when the ventilator
flow cycles from inspiration to expiration, in Pressure
Support mode.
The flow-cycling variable is given different names depending on the type of ventilator.
Also know as
Inspiratory flow termination,
Expiratory flow sensitivity,
Inspiratory flow cycle %,
E-cycle etc
Inspiratory Cycle Off
The breath ends when the ventilator detects inspiratory flow has dropped to a specific flow
value.
Inspiration ends
pressure
flow
Inspiratory Cycle Off
In the above example, the machine is set to cycle inspiration off at 30% of the patients
peak inspiratory flow.
100% of Patients
Peak Inspiratory Flow
F
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100%
50%
30%
75%
Inspiratory Cycle Off
A The cycle off percentage is too high, cycling off too soon. This makes the breath too
small. (not enough Vt.)
60%
10%
B The cycle off percentage is too low, making the breath too long. This forces the patient
to actively exhale (increase WOB), creating an exhalation spike.
Exhalation
spike
A B
100% 100%
Sources:
Rapid Interpretation of Ventilator Waveforms Ventilator
Waveform Analysis
Susan Pearson
Golden Moments in Mechanical Ventilation Maquet, inc.
Servo-I Graphics Maquet, inc.
text book of physiology- Ganong
David W Chang clinical application of mechanical
ventilation
Pulmonary function and graphics -Goldsmith


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