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
2. Increased airway resistance
3. Change in lung compliance
4. Hypoventilation
5. V/Q mismatch
6. Intrapulmonary shunting
7. 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
4. Inside the airway retained secretions
5. In the wall swelling or neoplasm
6. Outside the wall eg. tumor
 Simplified Poiseuille’s 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  CONDITIONS

2. STATIC 2. ATELECTASIS
3. ARDS
4. Pneumothorax
5. Obesity
6. Retained secretions

8. DYNAMIC 9. Bronchospasm
10. Kinking of ET tube
11. Airway obstruction
HIGH COMPLIANCE
 Emphysema
 Surfactant therapy
VENTILATORY FAILURE
 5 mechanisms lead to ventilatory failure
2. Hypoventilation
3. Persistent ventilation perfusion mismatch
4. Persistent intrapulmonary shunting
5. Diffusion defect
6. 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  CLINICAL CONDITIONS
2. Decrease in pressure 2. High altitude, fire
gradient combustion

5. Thickening of A-C 5. Pulmonary edema and

membrane retained secretions

7. Decrease surface 7. Emphysema ,

areaof A-C membrane pulmonary fibrosis

9. Insufficient time of 9. tachycardia

diffusion
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 patient’s response to ventilator.
• Monitors the patient’s disease status (C and Raw).
• Assesses patient’s 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 time…
time is the x axis
 Loops: plot pressure/volume/flow against each
other…there 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

Pressure
Pressure

Flow
Flow

Volume
Volume

Volume Control/ SIMV (Vol. Control) Pressure Control/ PRVC Pressure Support/
SIMV (PRVC) Volume Support
SIMV (Press. Control)
Pressure/Time Scalar
 In Pressure modes, the
• In Volume modes, shape will be rectangular
the shape will be or square.
an exponential  This means that pressure
rise or an remains constant
accelerating ramp throughout the breath
for mandatory cycle.
breaths.

•In Volume modes, adding an inspiratory pause may improve distribution of ventilation.
Pressure/Time Scalar
Can be used to assess:
•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
Pressure/Time Scalar

15

5 PEEP +5

No patient effort Patient effort

•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.
Pressure/Time Scalar
Inspiratory pause
1

A = MAP
B

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

A. B.
PIP PIP

Pplat
Pplat

•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
Can be used to assess:

•Air trapping (auto-PEEP)

•Leaks

•Tidal Volume
•Active Exhalation
•Asynchrony
Volume/Time Scalar

Inspiratory Tidal Volume

Exhaled volume returns

to baseline
Volume/Time Scalar
Air-Trapping or Leak

Loss of volume

•If the exhalation side of the waveform doesn’t return to baseline, it could be
from air-trapping or there could be a leak (ETT, vent circuit, chest tube, etc.)
Flow/Time Scalar
 In Volume modes, the
shape of the waveform will
 In Pressure modes,
be square or rectangular. (PC, PS, PRVC,
 This means that flow
remains constant
VS) the shape of
throughout the breath the waveform will
cycle. have a
decelerating ramp
flow pattern.
Flow/Time Scalar
Can be used to assess:

•Air trapping (auto-PEEP)

•Airway Obstruction
•Bronchodilator Response
•Active Exhalation
•Breath Type (Pressure vs. Volume)
•Flow Waveform Shape
•Inspiratory Flow
•Asynchrony
•Triggering Effort
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)
= Normal
Expiratory flow
doesn’t return to
baseline

Start of next breath

•If expiratory flow doesn’t return to baseline before the next breath starts, there’s auto-
PEEP (air trapping) present , e.g. emphysema.
Flow/Time Scalar
Bronchodilator Response
Pre-Bronchodilator Post-Bronchodilator

Longer Shorter
E-time E-time

Peak Exp. Flow

Improved Peak Exp. Flow

•To assess response to bronchodilator therapy, you should see an increase in peak
expiratory flow rate.

•The expiratory curve should return to baseline sooner.

Types of Waveforms
Volume Modes Pressure Modes

Pressure
Pressure

Flow
Flow

Volume
Volume

Volume Control/ SIMV (Vol. control) Pressure Control/ PRVC Pressure Support/
SIMV (PRVC) Volume Support
SIMV (Press. control)
•In Pressure Limited, Time-cycled (control) modes, inspiratory flow should return to baseline.
•In Flow-cycled (support) modes , flow does not return to baseline.
Types of Waveforms

•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.
Pressure/Volume Loops

500

250

5 15 30
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 there’s 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
Can be used to assess:

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

Dynamic
Compliance
B (Cdyn)
B = Exp. 500 n A = Inspiratory
io
Resistance/ irat
x p A Resistance/
Elastic WOB e Resistive WOB
on
ir ati
s p
250 in

5 15 30

•The top part of the P/V loop represents Dynamic compliance (Cdyn).
• Cdyn = Δvolume/Δpressure
Pressure/Volume Loops
Overdistention

“beaking”

500

250

5 15 30

•Pressure continues to rise with little or no change in volume, creating a “bird beak”.
•Fix by reducing amount of tidal volume delivered
Pressure/Volume Loops
Airway Resistance

e
anc
500
ist
es
p .r ”
ex s i s
re
s te
y
“h ce
an
250

is t
res
.
nsp
i
5 15 30

•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.
Pressure/Volume Loops

Increased Compliance Decreased Compliance

500 500

250 250

5 15 30 5 15 30

Example: Emphysema, Example: ARDS, CHF,

Surfactant Therapy Atelectasis
Pressure/Volume Loops
A Leak

500

250

5 15 30

•The expiratory portion of the loop doesn’t return to baseline. This indicates a leak.
Pressure/Volume Loops
Inflection Points

500

250

5 15 Lower 30

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.
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
60

40

20

0
200 400 600

-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 what’s set on
the ventilator.
 The shape of the exp flow curve represents passive
exhalation…it’s 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
Can be used to assess:

•Air trapping
•Airway Obstruction
•Airway Resistance
•Bronchodilator Response
•Insp/Exp Flow
•Flow Starvation
•Leaks
•Water or Secretion accumulation
•Asynchrony
Flow/Volume Loops
60

40

20
Start of Start of
Inspiration Expiration
0
200 400 600

-20

-40

-60
PEF
Flow/Volume Loops

0 0

•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
A Leak
60

= Normal
40

20

0
200 400 600

Expiratory -20
portion of loop
does not -40
return to starting
point, indicating
a leak. -60

•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.
Flow/Volume Loops
Airway Obstruction

0 0

Reduced
“scooping” PEF

•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.
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 doesn’t return to baseline before the next
breath begins.
• Volume wave: the expiratory portion doesn’t return to baseline.
• Flow/Volume Loop: the loop doesn’t meet at the baseline
• Pressure/Volume Loop: the loop doesn’t 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 • Increased compliance
• Causes • Causes
 Emphysema
 ARDS
 Surfactant Therapy
 Atelectasis
 Abdominal distension
 CHF
 Consolidation
 Fibrosis
 Hyperinflation
 Pneumothorax
 Pleural effusion
• How to Identify it on the
 How to Identify it on the graphics graphics
 Pressure wave: PIP and plateau
 Pressure wave: PIP and plateau both decrease
both increase
 Pressure/Volume loop: Stands
 Pressure/Volume loop: lays more vertical (upright)
more horizontal
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 doesn’t return to baseline
• Flow wave: PEF decreased
• Pressure/Volume loop: exp side doesn’t return to the baseline
• Flow/Volume loop: exp side doesn’t 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 patient’s demand in Pressure Support mode.

•In SIMV, rise time becomes a % of the breath cycle.
Rise Time
pressure spike

too fast too slow

 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 patient’s inspiratory demands. If this occurs,
you will need to decrease the rise time to open the valve faster.
Inspiratory Cycle Off
•The inspiratory cycle off determines when the
ventilator flow cycles from inspiration to expiration, in
Pressure Support mode.

Also know as–

•Inspiratory flow termination,
•Expiratory flow sensitivity,
•Inspiratory flow cycle %,
•E-cycle etc…

•The flow-cycling variable is given different names depending on the type of ventilator.
Inspiratory Cycle Off
Inspiration ends

pressure

flow

•The breath ends when the ventilator detects inspiratory flow has dropped to a specific
flow value.
Inspiratory Cycle Off
100% of Patient’s
Peak Inspiratory Flow
100%
75%
50%
Flow

30%

•In the above example, the machine is set to cycle inspiration off at 30% of the patient’s
peak inspiratory flow.
Inspiratory Cycle Off
Exhalation
A B
spike

100% 100%

60%
10%

•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”.
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
Thank You!