Ventilator grafik weapon

Scalars are waveforms that plot pressure, flow, or volume against time. Time is the x-axis.
Loops are waveforms that plot pressure or flow against volume. (P/V or F/V). There is no time component.
Loops Scalar

Types of waveforms

Pressure Waveform can be used to assess: Pressure Waveform (Pressure Control)

Air trapping (auto-PEEP)

Airway Obstruction
Bronchodilator Response
Respiratory Mechanics (C/Raw)
Active Exhalation
Breath Type (Pressure vs. Volume)
PIP, Pplat
CPAP, PEEP Remember…A square waveform represents a constant or
Asynchrony set parameter
Triggering Effort
Flow Waveform can be used to assess: Flow waveforms (Pressure control)

•Air trapping (auto-PEEP)

•Airway Obstruction
•Bronchodilator Response
•Active Exhalation
•Breath Type (Pressure vs. Volume)
•Inspiratory Flow
•Asynchrony
•Triggering Effort

Flow waveforms (Pressure control) Flow waveforms (Pressure control)

In patients with severe airway obstruction, this can become a problem in flow -
cycled modes of ventilation, such as Pressure Support If the expiratory portion of the waveform doesn’t return to baseline before the
start of the next breath starts, there could be air trapping. (emphysema,
improper I:E ratio)
FLOW WAVEFORMS

To assess response to bronchodilator therapy, you should

see an increase in peak
expiratory flow rate. Plus, the expiratory portion of the
curve should return to baseline
sooner.
VOLUME WAVEFORMS VOLUME WAVEFORMS

Can be used to assess:

Air trapping (auto-PEEP)
Leaks
Tidal Volume
Active Exhalation
Asynchrony

VOLUME WAVEFORMS

If the exhalation side of the waveform doesn’t return to
baseline, it could be from air-trapping or there could be a
leak (ET tube, vent circuit, chest tube, etc.)
Pressure mode vs volume mode
The area of no flow indicated by the red line is known as a
“zero-flow state”.
This indicates that I-time is too long for this patient.
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Question: How can I tell what type of mode (or type of

breath) is this? Is it Volume or Pressure?
Remember the letter “P”. In Pressure modes…The
Pressure waveform…has a Plateau.
Pressure/Volume Loops Pressure/Volume Loops

Can be used to assess:

Lung Overdistention
•Airway Obstruction
•Bronchodilator Response
•Respiratory Mechanics (C/Raw)
•WOB
•Flow Starvation
•Leaks
•Triggering Effort

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
The top part of the P/V loop represents Dynamic pressure breaths go counterclockwise. The bottom of the
compliance (Cdyn). loop will be at the set PEEP level. It will be at 0 if there’s no
• Cdyn = Δvolume/Δpressure 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 Pressure volume loops
Overdistension

Pressure continues to increase with little or no change in

The P-V loop becomes almost square shaped in pressure volume, creating a “bird beak”.
modes because of pressure Fix by reducing amount of tidal volume delivered
limiting (constant) , during the inspiration.
Pressure volume loops Pressure volume loops
Resistensi
Compliance

As airway resistance increases, the loop will become wider.

An increase in expiratory resistance is more commonly seen.
Increased expiratory Increased inspiratory
resistance: resistance:
secretions, ET size too small, kinked tube,
bronchospasms etc patient biting tube etc
Pressure volume loops Pressure volume loops

Leaks

Inflection point
The lower inflection point represents the point of alveolar
The expiratory portion of the loop doesn’t return to opening (recruitment).
baseline. This indicates a leak. •Some lung protection strategies for treating ARDS,
suggest setting PEEP just above the lower inflection point.
Flow Volume Loops 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 Flow volume loops
•Air trapping
•Airway Obstruction
•Airway Resistance
•Bronchodilator Response
•Insp/Exp Flow
•Flow Starvation
•Leaks
•Water or Secretion accumulation The shape of the inspiratory portion of the curve will
•Asynchrony match the flow waveform.
Flow volume loops Flow volume loops
Leak
Airway obstruction

The expiratory part of the curve “scoops” with diseases

If there is a leak, the loop will not meet at the starting point that cause small airway
where inhalation starts and exhalation ends. It can also occur obstruction (high expiratory resistance). e.g. asthma,
with air-trapping. emphysema.
Air Trapping (auto-PEEP) Airway Resistance Changes
Causes: Causes:
• Insufficient expiratory time • Bronchospasm
• Early collapse of unstable alveoli/airways during • ETT problems (too small, kinked, obstructed, patient
exhalation biting)
• High flow rate
How to Identify it on the graphics • Secretion build-up
• Pressure wave: while performing an expiratory hold, • Damp or blocked expiratory valve/filter
the waveform rises • Water in the HME
above baseline. How to Identify it on the graphics
• Flow wave: the expiratory flow doesn’t return to • Pressure wave: PIP increases, but the plateau stays the
baseline before the next same
breath begins. • Flow wave: it takes longer for the exp side to reach
• Volume wave: the expiratory portion doesn’t return to baseline/exp flow
baseline. rate is reduced
• Flow/Volume Loop: the loop doesn’t meet at the • Volume wave: it takes longer for the exp curve to reach
baseline the baseline
• Pressure/Volume Loop: the loop doesn’t meet at the • Pressure/Volume loop: the loop will be wider. Increase
baseline Insp. Resistance
How to Fix: will cause it to bulge to the right. Exp resistance, bulges to
• Give a treatment, adjust I-time, increase flow, add the left.
PEEP. • 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 Increased compliance Causes
•Expiratory leak: ETT cuff leak , chest tube leak, BP fistula,
Causes Causes NG
ARDS Emphysema tube in trachea
Atelectasis Surfactant Therapy • Inspiratory leak: loose connections, ventilator
Abdominal distension malfunction,
CHF faulty flow sensor
Consolidation
Fibrosis How to ID it
Hyperinflation • Pressure wave: Decreased PIP
Pneumothorax • Volume wave: Expiratory side of wave doesn’t return to
Pleural effusion baseline
How to Identify it on the How to Identify it on the • Flow wave: PEF decreased
graphics graphics • Pressure/Volume loop: exp side doesn’t return to the
Pressure wave: PIP and Pressure wave: PIP and baseline
plateau both increase plateau both decrease • Flow/Volume loop: exp side doesn’t return to baseline
Pressure/Volume loop: Pressure/Volume loop:
lays more horizontal Stands more vertical How to fix it
(upright) • Check possible causes listed above
• Do a leak test and make sure all connections are tight
 Rise time
Rise Time &
Inspiratory Cycle Off %

If rise time is too fast, you can get an overshoot in the

The inspiratory rise time determines the amount of
time it takes to reach the desired pressure setting in
Pressure Support mode.
In SIMV mode, rise time becomes a % of the breath
cycle.
The inspiratory cycle off
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 patient’s
inspiratory demands. If this occurs, you will need to
decrease the rise time to open the valve faster.
The 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 brand of ventilator.
Also know as–
•Inspiratory flow termination,
•Expiratory flow sensitivity,
•Inspiratory flow cycle %,
•E-cycle, etc…

Inspiratory cycle Inspiratory cycle

In the above example, the machine is set to cycle
inspiration off at 30% of the patient’s
peak inspiratory flow.
A : The cycle off percentage is too high, cycling off too
soon. This makes the breath too small. (not enough Vt.)
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”.