BASICS OF WAVEFORM

INTERPRETATION

Principles of Mechanical Ventilation

新光醫院急診科王宗倫主任
101.01.16

Objectives
• Identify graphic display options
provided by mechanical ventilators.
• Describe how to use graphics to
more appropriately adjust the patient
ventilator interface.
Introduction
Monitoring and analysis of graphic display
of curves and loops during mechanical
ventilation has become a useful way to
determine not only how patient are being
ventilated but also a way to assess
problems occurring during ventilation.

Uses of Flow, Volume, and Uses of Flow, Volume, and

Pressure Graphic Display Pressure Graphic Display

• Confirm mode functions • Evaluate adequacy of inspiratory time in pressure

• Detect auto-PEEP control ventilation
• Determine patient-ventilator synchrony • Detect the presence and rate of continuous leaks
• Assess and adjust trigger levels • Assess inspiratory termination criteria during
Pressure Support Ventilation
• Measure the work of breathing
• Determine appropriate Rise Time
• Adjust tidal volume and minimize overdistension
• Assess the effect of bronchodilator administration
• Detect equipment malfunctions
• Determine appropriate PEEP level

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 Measured Parameters Most Commonly Used
Waveforms (Scalars)
Flow
Pressure • Pressure vs. Time
Volume
Time • Flow vs. Time

• Volume vs. Time

Pressure vs. Time Curve Pressure-Time Curve

30
20

A B
C Volume Ventilation Pressure Ventilation
PIP

Baseline
Paw
cmH2O Sec
Paw Mean Airway Pressure
1 2 3 4 5 6
cmH2O Sec
1 2 3 4 5 6
-10

Adequate Flow During

Patient Triggering
Volume-Control Ventilation
30 30

Adequate flow

Paw Paw
cmH2O cmH2O
1 2 3 4
Sec
1 2
Time (s)
5 6 3
-10
-10

2
 Inadequate Flow During
Patient/Ventilator Synchrony
Volume-Control Ventilation Volume Ventilator Delivering a Preset Flow and Volume

30
Adequate Flow
Adequate flow

Paw Sec

cmH2O
Paw 1 2 3 4 5 6
cmH2O Flow set too low
1 2
Time (s)
3

-10 -20

Patient/Ventilator Synchrony Plateau Time

The Patient Outbreathing the Set Flow
30

Air Starvation Inadequate plateau time

Paw Sec
SEC
cmH2O Paw
1 2 3 4 5 6 cmH2O 1 2 3 4 5 6

-20
-20

Plateau Time
Flow vs.Time Curve
30
120
INSP
Adequate Plateau Time Inspiration

.
V
SEC
LPM 1 2 3 4 5 6
SEC
Paw
cmH2O 1 2 3 4 5 6
EXH
120

-20

3
 Flow vs.Time Curve Flow vs.Time Curve
120 120 Constant Flow Descending Ramp
INSP INSP
Inspiration
Inspiration

.
V
.
V
SEC SEC
LPM 1 2 3 LPM 1 2 3
4 5 6 4 5 6

Expiration

EXH EXH
120 120

Flow-Time Curve Inspiratory Time

Short Normal Long
120
INSP

.
V
Insp. Pause
SEC
LPM 1 2 3 4 5 6

Expiration

EXH
120

A Higher Expiratory Flow Rate and a

Expiratory Flow Rate and Changes
Decreased Expiratory Time Denote a Lower
in Expiratory Resistance Expiratory Resistance
120 120

.
V SEC
.
V SEC

LPM LPM
1 2 3 4 5 6 1 2 3 4 5 6

-120 120

4
 Pressure-Time and Flow-Time Curves
Obstructed Lung

20

Volume Ventilation

Expiration
Paw
cmH2O Sec
1 2 3 4 5 6

.
V
Delayed flow return

Pressure-Time and Flow-Time Curves

Different Inspiratory Flow Patterns Pressure-Time and Flow-Time Curves

20
20
Volume Ventilation
Volume Ventilation Pressure Ventilation

Expiration Inspiratory Time

Paw Inspiration
Paw
cmH2O Sec cmH2O Sec
1 2 3 4 5 6 1 2 3 4 5 6

. .
V V

Flow Acceleration Percent

Rise Time
Rise Time Minimal Pressure Overshoot

How quickly set pressure is reached P

Slow rise Moderate rise Fast rise

.
V

Pressure Relief

Time

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 Patient / Ventilator Synchrony Patient -Ventilator Synchrony
Volume Ventilation Delivering a Preset Flow and Volume The Patient Is Outbreathing the Set Flow
30 30

Adequate Flow Air Starvation

Paw Sec Paw Sec

cmH2O cmH2O
1 2 3 4 5 6 1 2 3 4 5 6

-20 -20

If Peak Flow Remains the Same, I-Time Changing Flow Waveform in Volume
Increases: Could Cause Asynchrony Ventilation: Effect on Inspiratory Time

120 120

.
V
.
V
SEC SEC
LPM LPM
1 2 3 4 5 6 1 2 3 4 5 6

-120 -120

Increased Peak Flow: Decreased

Detecting Auto-PEEP
Inspiratory Time
120 120

.
V
.
V
SEC SEC
LPM LPM
1 2 3 4 5 6 1 2 3 4 5 6

Zero flow at end exhalation indicates

equilibration of lung and circuit pressure
-120 -120

Note: There can still be pressure in the lung behind

airways that are completely obstructed

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 Detecting Auto-PEEP
Volume vs.Time Curve
120 800 ml

.
V Inspiration
SEC VT
LPM
1 2 3 4 5 6
SEC

1 2 3 4 5 6
The transition from expiratory to inspiratory
120
occurs without the expiratory flow returning
to zero

Volume vs.Time Curve Typical Volume Curve

800 ml
I-Time
E-Time
1.2

Expiration
VT A B

SEC VT
Liters SEC
1 2 3 4 5 6 1 2 3 4 5 6
-0.4
A = inspiratory volume
B = expiratory volume

Setting Appropriate I-Time

Leaks
600 cc
450 cc
VT
1.2
SEC

A 0 1 2 3 4 5 6
120

VT SEC .
Liters V SEC
1 2 3 4 5 6 LPM 1 2 3 4 5 6
-0.4

A = exhalation that does not return to zero 120

7
 Setting Appropriate I-Time
Loops
600 cc
450 cc 500 cc
VT
SEC

0 1 2 3 4 5 6 • Pressure-Volume Loops
120
Lost VT
.
V SEC
LPM 1 2 3 4 5 6
• Flow-Volume Loops
120

Pressure-Volume Loop Mandatory Breath

VT VT
LITERS LITERS

0.6 0.6

0.4 0.4

Inspiration
0.2 0.2

Paw Paw
cmH2O -60 40 20 0 20 40 60 cmH2O -60 40 20 0 20 40 60

Mandatory Breath Spontaneous Breath

VT VT
Counterclockwise Clockwise
LITERS LITERS

0.6 0.6

Expiration
0.4 0.4
Inspiration
Inspiration
0.2 0.2

Paw Paw
cmH2O -60 40 20 0 20 40 60 cmH2O -60 40 20 0 20 40 60

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 Spontaneous Breath Work of Breathing
VT VT
LITERS Clockwise
LITERS
0.6
0.6

0.4 0.4
Inspiration
Expiration
0.2
0.2

Paw
cmH2O -60 40 20 0 20 40 60 Paw
-60 -40 -20 0 20 40 60
cmH2O

Assisted Breath Assisted Breath

VT VT
LITERS LITERS

0.6 0.6

0.4 0.4

Assisted Breath 0.2 Assisted Breath 0.2

Inspiration

Paw Paw
cmH2O -60 40 20 0 20 40 60 cmH2O -60 40 20 0 20 40 60

Assisted Breath Pressure-Volume Loop Changes

VT Clockwise to Counterclockwise VT
LITERS
LITERS
0.6
0.6
Expiration
0.4 0.4

Assisted Breath 0.2

Inspiration 0.2

Paw
cmH2O -60 40 20 0 20 40 60 Paw
-60 -40 -20 0 20 40 60
cmH2O

9
 Changes in Compliances Overdistension
Indicates a drop in compliance
VT (higher pressure for the same VT
A = inspiratory pressure
LITERS volume) LITERS
B = upper inflection point
0.6 0.6
C = lower inflection point A
0.4 0.4

0.2 0.2
B

C
Paw Paw
-60 40 20 0 20 40 60 -60 -40 -20 0 20 40 60
cmH2O cmH2O

Lung Overdistension Normal Flow-Volume Loops

Flow -Volume Loops Flow -Volume Loops

Volume Control Volume Control
Tidal Volume Tidal Volume
Peak Inspiratory Flow
Peak Expiratory Flow

Inspiration Inspiration

Volume Volume

Expiration Expiration

10
 ETT or Circuit Leaks Obstructive Pattern

Bronchodilator Response Bronchodilator Response

BEFORE BEFORE AFTER
Worse
3 3 3

2 2 2

1 1 1
.
V
.
V
.
V
.
V
LPS LPS LPS LPS
1 1 1

2 2 2

3 3 3

Remember!
Bronchodilator Response Waveforms and loops are graphical representation of the
data generated by the ventilator.
BEFORE AFTER
Typical Tracings
Worse Better
3 3 3 Pressure-time,
INSP Flow-time,
2 2 2
Volume -time
1 1 1 Loops
.
V
.
V
.
V Pressure-Volume
VT
LPS LPS LPS
Flow-Volume
1 1 1

2 2
3 3
2
Assessment of pressure, flow and volume
3
EXH
waveforms is a critical tool in the management
of the mechanically ventilated patient.

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