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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
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
3. Spontaneous breaths
Pressure above baseline = expiration
Ti
Ti
Ti
Ti
Airway Pressure
Ppeak = Pairway + Pplateau
Change in Compliance
Paw = Pr+Palv+Ppl
Ppl ~ 0
then Paw=Pr+Palv
Palv
increase compliance
decrease compliance
parenchymal disease
pleural disease
No !! This is unstable pressure plateau, possibly due to a leak or the patients inspiratory effort.
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)
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
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
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
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
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
PCV
Changes in Ti
Volume-Time Curve
Applications : Air-trapping detection Leaks in the patient circuit detection
Volume-Time Curve
Leak or Air-Trapping
Air-trapping in COPD
Controlled
Assisted
PEEP5
PEEP5
PEEP5
Pressure preset
PEEP 6
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
PEEP
Breath type
Breath type
Breath type
Trigger tail
Assessing compliance
Increased Resistance
Lung overdistention
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 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?
ACCP-SEEK 2006