Babylog 8000

Guide to Pressure Waves

1-127-94

Hartmut Schmidt
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© 1994 by Drägerwerk AG, Lübeck, Germany
All rights reserved. No part of this brochure may by reproduced or copied for public
use by any mechanical, photografic or electronic process.

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Introduction

Pressure is the driving force for all modes of ventilation commonly

used with neonates. Measured pressure values like mean airway
pressure, peak inspiratory pressure and positive end expiratory
pressure should therefore form the basic monitoring for all neonatal
ventilators. Nevertheless, these quasi static parameters prove only
that the pressures you set are actually produced by the ventilator. The
dynamic behaviour of ventilator and patient can not be assessed using
these values. Even the pressures displayed by a pressure gauge are
difficult to read, especially at higher breathing rates. The graphics
display of the Babylog 8000 ventilator series provides convenient
access to the dynamics of pressure. This booklet provides a short
guide to the benefits of pressure-time curves.

How the Babylog 8000 measures pressure

The Babylog 8000 does not have a proximal pressure measurement

hose. Measuring the airway pressure with such a measurement hose
is a convenient method, but only for the design engineer. In clinical use
these hoses tend to cause continuous trouble. The measurement
hose requires extra handling and care, and in addition water droplets
can easily occlude the hose. In event of a partial or total occlusion all
pressure displays and alarms are incorrect. With big droplets of
mucus or condensation the complete measurement system is incor-
rect, and there is no possibility to detect this situation. Contemporary
ventilators also use pressures measured by pressure measurement
hoses for servo loops to keep the airway pressure constant. If the
pressure measurement is already incorrect, the resultant pressure
control will be even worse. Some ventilators use purge flows in the
measurement lines, but then it is important to use the correct tube,
diameter and length. Kinking this hose, even just a little bit, causes the
same measurement inaccuracies.

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The Babylog 8000 has a different approach to pressure measure-
ment. Two pressure transducers, one at the inspiratory gas outlet and
one at the expiratory valve, measure the pressures. A mathematical
model of the tubing is used to calculate pressure at the wye. This type
of measurement has proved to be precise over the entire flow range.
It is compatible with all available humidifiers and tubing systems.

With this method of pressure measurement no additional proximal

pressure hose is neccessary. In addition there are no problems with
condensation, hose kinking etc.

Proximal Airway Pressure

The Proximal Airway Pressure (Paw) is the pressure present at the

wye piece in the tubing system. Fig. 1 shows this pressure versus
time. The horizontal axis represents time, the vertical axis represents
pressure.

An inspiration is shown as a rise in pressure. The Peak Inspiratory

Pressure (PIP) appears at the highest point of the curve. During the
expiratory time (Te) the pressure drops to the baseline pressure. This
pressure is called the Continuous Positive Airway Pressure (CPAP)
or Positive End Expiratory Pressure (PEEP) depending on the mode
of ventilation. This baseline pressure is maintained until the next
inspiration.

Fig. 1

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Average (mean) airway pressure is calculated from the shaded area
under the pressure waveform.

Using the inspiratory pressure limit (Pinsp) control of the

Babylog 8000, the maximum pressure delivered to the wye piece can
be set. The airway pressure is limited to this maximum. If pressure
reaches this limit, a plateau occurs. In the Babylog 8000 screen this
set pressure limit is displayed as a dotted line (Fig. 2).

Fig. 2

The peak inspiratory pressure, as well as mean airway pressure and

PEEP are displayed along with the real time pressure-time curve. This
combination of quasi static and dynamic information offers direct
feedback on how settings affect ventilation. This feedback allows
assessment of the effect of different flow rates and precise control
over plateau pressures.

Pinsp and PEEP are the standard controls used in adjusting pressu-
res. However another parameter, the insipiratory flow rate, has an
often underestimated influence on airway pressure. Flow rate set-
tings effect the ability of the ventilator to attain desired levels of peak
inspiratory pressure, desired wave forms, I:E ratios, and, in some
cases, respiratory rate [1].

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Setting Lower Flow Rates

Setting lower flow rates can effect tidal volumes and therefore CO2
removal. They can also effect mean airway pressure and therefore
oxygenation. Lower flow rates result in a slower increase in airway
pressure, depicted as a triangular (sloping) pressure wave form on
the Babylog display screen. This results in a sinusoidal gas flow into
the patient, better resembling a spontaneous breathing pattern. If
short inspiratory times are used, Ti may not be long enough to reach
the set peak pressure limit. In this case, tidal volumes will be impaired
which may result in hypercapnia. At the same Peak pressure setting,
a sloping wave form (as opposed to a square wave) will result in a
decreased area under the pressure wave form, and therefore a lower
mean airway pressure. This may result in a decrease in PaO2. It has
been proposed on theoretical grounds that less barotrauma may be
associated with ventilation using this curve[1 ].

Fig. 3

Setting Higher Flow Rates

A higher flow rate setting results in an immediate pressure increase
depicted as a square pressure wave form on the Babylog display
screen. The result is a high initial flow into the patient, delivering the
tidal volume early in inspiration. The Peak pressure limit is reached
early on in inspiration so that a longer portion of the inspiratory time is
spent at Peak Pressure. This results in an increase in mean airway
pressure and consequently an increase in PaO2 may occur. The longer
time spent at Peak pressure may open up atelectatic alveoli and
improve distribution of ventilation but could impede venous return.
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Measured Pressure Values

Mean Airway Pressure

Mean Airway pressure is an important control for the maintenance of
oxygenation. It is calculated as the area under the pressure-time curve
divided by the time for one ventilator cycle. This measurement is
automatically performed by the ventilator.

Fig. 4

There are five different ways to increase mean airway pressure:

1 increase inspiratory flow rate

2 increase peak inspiratory pressure
3 increase inspiratory time
4 increase PEEP
5 reduce expiratory time

The effect of altering these parameters can be seen on the pressure

wave form display of the Babylog. The area of the pressure waveform
is coloured black in the display for easier visualisation of the mean
airway pressure (area under the pressure curve).
Care should be taken when manipulating the above parameters to
adjust mean airway pressure as they also affect ‘Pip - PEEP’ (delta
Pressure) at the airway. This in turn effects tidal volume and minute
ventilation resulting in a change in PaCO2. Mean airway pressure can
be adjusted to improve oxygenation without altering tidal volume or
minute ventilation when ventilating with a pressure plateau waveform
(square wave). In this situation adjusting inspiratory flow rate will
influence mean airway pressure and oxygenation without effecting
ventilation.
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Note that mean airway pressure is independent of the frequency if l:E
stays constant. It has been substantiated in animals, that the mean
airway pressure is the same as the mean lung pressure [2]. However,
mean airway pressure may over estimate mean alveolar pressure if
there is a substantial leak around the endotracheal tube [3].

The oxygenation of the patient is maintained by controlling the FiO2

and the mean airway pressure. Therefore these two parameters are
trended in the Babylog 8000 for 24hrs. Fig 5 shows a one hour
window of the mean airway pressure trend.

Fig. 5

Peak Inspiratory Pressure (PiP)

The measured PiP indicates the maximum pressure that has occured
during the last ventilatory cycle. It is normally below or equal to the set
maximum PIP. It may be higher than the set pressure limit, when a
patient has hick-ups, is coughing or crying .

PEEP / CPAP

PEEP or CPAP is the baseline pressure and controls the Functional

Residual Capacity (FRC) in the patients lung. Care should be taken
to set the PEEP properly and therefore a precise PEEP measurement
display is required. The Babylog displays PEEP values with extra
precision, even to the first decimal place.

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As PEEP is so important, the PEEP effective at the wye piece should
equal the set PEEP value. High flows rates, and narrow tubing may
create an artificial PEEP, so called inadvertent PEEP. Unlike many
other ventilators, the PEEP of the Babylog 8000 is not flow depen-
dent. The Babylog 8000 controls the PEEP with a servo loop and
automatically compensates for any inadvertent PEEP, even at high
flow rates of 30 L/min. This feature is important because with PEEP
independent of flow, the flow need not always be set to the usual
8 L/min. Instead flow can be used freely to control the shape of the
pressure waveform.

Pressure-time Curves
In addition to measured pressure values, dynamic information is often
required. Of particular interest are the pressure rise time and the
length of the pressure limited plateau. At higher breath rates this
information can hardly be obtained from a standard pressure gauge.
Pressure time curves present this information very clearly.

Pressure-time curves provide the following additional information:

– The type of breath delivered to the patient

– The timing and adequacy of inspiration
– The adequacy of plateau pressure
– The adequacy of the flow rate
– The pressure waveform shape
– The influences of the humidifier and tubing on ventilation

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Time Cycled Breaths
Without any trigger mechanism involved, an inspiration is started,
when the set expiratory time, Te has elapsed. These mandatory
strokes can be identified as strokes that have no negative deflection
before the start of inspiration.

Fig. 6

Patient Triggered Breaths

When a pressure trigger is used, a mandatory breath is initiated when
the pressure at the wye piece drops below a preset level. In this case
a pressure triggered breath is indicated by a negative pressure
deflection before the rise in pressure.

If the flow-triggering option of the Babylog 8000 is used, these

negative pressure deflections can not be seen. The high sensitivity of
the flow trigger virtually eliminates the patient effort (imposed work)
exerted to trigger a breath.

Adjusting Flow Rate

The ventilator flow rate and the compliance of patient and tubing
determine the pressure rise time (slope) of the pressure wave during
an inspiratory cycle. Therefore the flow rate can be used to adjust the
shape of the pressure waveform.

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It takes longer for pressure to reach the pressure limit if a small flow
rate has to fill up a large lung compliance. A high flow rate will quickly
fill up a low lung compliance increasing pressure quickly, resulting in
a shorter pressure rise time.

Fig. 7

Increase flow rate if

– the rise of pressure is too slow
– a plateau is desired, but pressure does not reach the
pressure limit
– the given flow rate is not high enough to cope with the patient’s
spontaneous efforts, indicated by an impaired pressure slope;
in Fig. 8 the shaded area indicates the ideal shape

Fig. 8

Decrease flow rate if

– the pressure rise time is too short
– a pressure limit is reached creating a plateau when no plateau is
desired
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Assessing Plateau Pressure
In neonatal ventilation pressure limited pressure waveforms are
frequently used. However, sometimes pressure waveforms without
plateau are required. In the Babylog 8000 screen the pressure limit
(set Pinsp) is displayed as a dotted line making it easy to set ventilation
with or without a pressure plateau. The airway pressure is limited to
the dotted line (the set pressure limit). If pressure reaches this limit,
a plateau occurs. By altering the flow rate, theshape of the pressure
waveform can be adjusted to the exact shape required. The set
pressure limit safeguards against high pressures. Fig. 9 shows a
ventilation pattern without a pressure plateau. In Fig. 10 the flow rate
is increased creating a quicker pressure rise time (steeper slope)
reaching the pressure limit before the end of inspiration and therefore
a plateau is seen. Note the differences the flow rate makes to mean
airway pressure.

Fig. 9

Fig. 10

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Influence of the Humidifiers and Tubing Systems

The flow delivered by the ventilator ventilates both the patient and the
tubing system. If the compressible volume of the humidifier and of the
tubing is high, less flow is delivered to the patient. This situation is
indicated by a lower pressure rise during inspiration. Different humi-
difiers and tubing systems require different flow settings to achieve a
particular pressure waveform. Furthermore, increased compressible
volumes may occur as the water level falls in the humidification
chamber. Fig. 10 shows the resultant pressure waveforms produced
from using two different humidifiers at the same flow rate setting. Note
the differences in Mean Airway Pressure.

Fig. 11 Dräger Aquamod

Fig. 12 Standard Humidifier

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Spontaneous Breaths
Small fluctuations in pressure represent a patient’s spontaneous
breathing efforts. Negative pressure represents inspiration, while
positive pressure represents exhalation. Due to the continuous flow
system and the microprocessor controlled servo loop for the pressu-
re, these fluctuations are small with the Babylog 8000. They are often
hardly detectable on the graphics screen. Spontaneously breathing
patients with higher flow requirements may cause bigger fluctuations
if the flow rate is set too low (see Fig.13). In this case increase the flow
rate.

Fig. 13

Conclusion
This handbook shows some applications of the pressure time curves.
It is obvious, that the pressure real time graphics teaches us a great
deal about patient and ventilator interaction. Nevertheless, we have
to keep in mind, that pressure is only the driving force for flow and
volume. Detailed feedback on the patients pulmonary situation requi-
re assessment of flow waveforms and volume measurements [4].

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References
[1] William W. Fox, Alan R. Spitzer, John G. Shutack. Positive
pressure Ventilation: Pressure and time cycled Ventilators. In Golds-
mith, Karotkin (eds): Assistet Ventilation of the neonate, Philadelphia,
W. Saunders Co. 1988.

[2] Fuhrman BP, Smith-Wright DL, Venkataraman S, Orr RA,

Howland DF. Proximal mean airway pressure: A good estimator of
mean alveolar pressure during continuous positive pressure
breathing. Crit Care Med 1989; 17:666-670.

[3] Perez-Fontan JJ, Heldt GP, Gregory GG. The effect of a gas leak
around the endotracheal tube on the mean tracheal pressure during
mechanical ventilation.
Am Rev Respir Dis 1985; 132:339-342.

[4] Bartholomew K, Newell S, Dear P, Brownlee K

Babylog 8000 - Flow Wave and Volume Monitoring
Drägerwerk AG, Lübeck, 9097338, 1994.

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