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• Sinusoidal: also called the sine wave
• Exponential rising
• Exponential decaying
Pressure waveforms usually are rectangular or rising
exponential (similar to an ascending ramp) type.
Volume waveforms usually are ascending ramp or
sinusoidal (sine-like) type. Flow waveforms can
take various forms: rectangular, ramp (ascending or
descending), sinusoidal, and decaying exponential
types. Many clinicians refer to ramp waveforms
(and sometimes exponential waveforms) as either
“accelerating” or “decelerating” flow patterns. To
denote flow changes, it is more appropriate to label it as
increasing flow or a decreasing flow (or an accelerating
volume or a decelerating volume), rather than an
accelerating flow or a decelerating flow4. In theory, a
relatively slow rise to the peak inspiratory flow – as
is provided within the ascending-ramp and sinusoidal
waveforms – provides more time for gas distribution
within the lungs, and thereby improves oxygenation.
But slow flows in theses can be uncomfortable for the
patient and may cause air hunger. The constant flow
waveform and the descending ramp flow waveform
(the latter delivers high initial flows) are superior at
preventing “flow starvation”.
Fig 1. Examples of waveforms/scalars for pressure, volume, and
flow.
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Step 1. Identify type of breath: Constant flow and
Descending Ramp
Volume: In the volume-controlled mode, each
machine breath is usually delivered with the same
predetermined inspiratory flow–time profile to
reach a targeted volume. Because the area under a
flow–time curve defines volume, the tidal volume
remains fixed and pressure becomes the dependent
variable. The inspiratory pressure-time waveform
varies linearly with time and will change depending
on the compliance and resistance of the system.
Thereby monitoring and restricting pressure becomes
important in volume-control mode. During volume-
targeted ventilation, the most commonly used flow
waveform is the square flow waveform (constant flow
waveform) and from here on in this article volume
breath will be considered as synonymous for constant
flow for simpler understanding. The events during a
constant flow breath are the following (fig 2):
i) In flow time scalar (fig 2) –
Inspiration is displayed as a positive deflection and
expiration as a negative deflection.
A. The beginning of inspiration
B. Inspiratory flow rapidly rises to a peak.
C. Thereafter, flow is sustained at a constant level
(the square waveform has been applied) until the
entire preset tidal volume has been delivered, in
the given time.
D. From this point, the flow declines sharply to zero.
E. During the end-inspiratory pause, the breath is
briefly held within the lungs for the duration of
the applied pause, helps us to measure plateau
pressure.
F. Commencement of exhalation
G. The peak expiratory flow is rapidly reached.
H. Exhalation is passive, and so there is an exponential
decay in the inspiratory flow down to the baseline
as the lung progressively empties.
ii) In pressure time scalar (fig 2):
A. The beginning of inspiration. The presence of
a negative deflection here would mean that the
breath is patient-triggered. Its absence means
that the ventilator is responsible for triggering the
breath.
B. The initial rise in airway pressure is on account of
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Fig 2. Scalar events (flow, pressure, volume) during a volume controlled ventilation. a) Describes the event in detail with
markings. b) Describes the same event highlighting constant flow and inspiratory pause in flow time scalar & corresponding plateau
pressure in pressure time scalar.
the resistance offered by the ETT and ventilator
circuit. This pressure is called the flow resistive
pressure or the trans-airway pressure (Pta).
C. As the lung begins to distend, pressure is required
to overcome its resistive and elastic components.
The pressure it takes to overcome elastic forces is
the peak alveolar pressure (Palv)
D. When a constant flow is applied—the square
waveform—there is a gradual but uniform rate
of rise in the airway opening pressure until the
entire tidal volume has been delivered. The peak
inspiratory pressure is reached here at point D,
which strongly reflects both airway resistance and
alveolar pressure.
E. The pressure settles down, when inspiratory pause
is applied.
F. End inspiratory pause. This represents the plateau
pressure, which reflects the pressure applied to
small airways and alveoli and if high is considered
to be mostly responsible for stretch injury of alveoli;
in pathogenesis of ventilator induced lung injury.
G & H. Exhalation
Pressure: When a ventilator operates as a constant-
pressure control (for example, pressure-control
mode, pressure-regulated volume control mode or
synchronized intermittent mandatory ventilation-
pressure control (SIMV-PC) mode), pressure is an
independent, or controlled, variable (fig.3). The set
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pressure will be delivered and maintained constant
throughout inspiration, independent of what resistive
or elastic forces of the respiratory system might be.
Even though pressure is constant, the delivered tidal
volume will vary as a function of compliance and
resistance, and the flow will also vary exponentially
with time. The volume becomes a function of
compliance, so that a decrease in compliance means
less volume will be delivered for the same pressure.
The events during an ideal breath in pressure control
mode are the following (fig 3):
i) In flow time scalar (Fig 3, i) -
A. The beginning of inspiration (can be flow triggered
in assisted control or time triggered in control
mode)
B. Inspiratory flow rapidly rises to a peak, corresponding
to operator set peak inspiratory pressure.
C. Thereafter, flow rate rapidly declines as the
patient’s lung fill with air (the descending RAMP
waveform has been applied) at the same preset
inspiratory pressure in pressure control mode
and commencement of exhalation starts as per
set inspiratory time in control mode or as per
percentage of peak flow in pressure support mode.
D. Exhalation is passive, and so there is an exponential
decay in the inspiratory flow down to the baseline
as the lung progressively empties.
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ii) In pressure time scalar (Fig 3, ii): pressure or PIP) – the maximum pressure recorded
A. The beginning of inspiration. The presence of a within the airway during a ventilator-delivered
negative deflection here would mean that the breath breath. The peak airway pressure is influenced both
is patient-triggered. Its absence means that the by airway resistance and compliance; therefore, the
ventilator is responsible for triggering the breath. peak airway pressure can be high either on account
B. The pressure immediately rises to operator set of narrowed airways or stiff lung (fig 4).
peak inspiratory pressure.
C. The peak inspiratory pressure is reached and
remains same till the set inspiratory time in control
mode. As pressure is preset, pressure-time diagrams
show either no changes, or changes which are hard
to detect, as a consequence of changes in resistance
and compliance of the entire system.
D. At the end of pre-set inspiratory time, pressure
drops to zero.

Fig 4: Causes of raised peak airway pressures.

Plateau pressure: At the end of inspiration, during

Fig 3. Scalar events (flow, pressure, volume) during pressure
controlled ventilation.
All pressure modes are associated with a “descending
RAMP” flow pattern during inspiration. This
descending flow pattern represents the speed of the
gas, which is initially very high but gradually lowers
as the chest fills. This characteristic flow pattern is
considered more physiologic than that associated
with volume-based ventilation and may contribute to
better gas distribution as well5,6.
inspiratory pause, the airway pressure falls to a
plateau as the air diffuses out to the periphery of the
trachea-bronchial tree. The pressure within the airway
during this period of no airflow is called the pause
pressure or the plateau pressure, Pplat. The plateau
pressure is a reflection of the static compliance, and
so, any condition that stiffens the lung will increase
the plateau pressure7,8,9.
To differentiate low compliance from increased
airway resistance, interpretation of pressure time
scalar in volume control mode with inspiratory pause
is needed (fig 5)

Step 2. Identify reason for raised peak airway

pressure and to differentiate low compliance of
lung from increased airway resistance.
Peak airway pressure: During a ventilator-driven
tidal breath, the airway pressure rises rapidly to a
peak. This is the peak airway pressure (peak inflation

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Fig 5: Pressure–time scalar in constant flow with inspiratory
pause: i) normal lung, ii) increased airway resistance, iii)
decreased compliance.
Static compliance is measured in the absence of gas
flow, and is based on plateau pressure:
Cstat = Vt/(Pplat - PEEP)
Dynamic compliance is measure in the presence of
gas flow, and is based on peak pressure:
Cdyn = Vt/(Ppeak - PEEP)
Conditions that stiffen the lung, therefore, will
decrease both dynamic and static compliance,
whereas, conditions that produce airway narrowing
will produce a fall in dynamic compliance without
affecting the static compliance.
Step 3. Interpret Pressure volume (PV) loop
The PV loop has gained interest in the last decade,
because of the concept of gentle ventilation.
Ventilator induced over-distention (volutrauma and
barotraumas) and under-recruitment (atelectotrauma)
contribute to less effective ventilation, decreased
system compliance and as mechanism for ventilator
induced lung injury. Analysis and careful monitoring
of dynamic PV loop can guide us for optimal
ventilation.
Static PV loops:
The static PV loop is obtained as a result of the super-
syringe method11. Volume graphed against pressure
yields the compliance curve, (C = DV / DP)12. Thus
the PV loop shows how compliance develops as
volume increases. The lower and upper inflection
points can be taken from the static PV loop (fig 6). In
the lower section (A) the pressure per volume increase
rises particularly rapidly. It continues in a straight line
(B) with gradual slope once a lung-opening pressure
(lower inflection point) has been exceeded. If the
lung reaches the limits of its compliance, the rise in
pressure per volume increase becomes bigger again
(upper inflection point) (C). The lower inflection point
(LIP) is thought to represent the pressure at which
a large number of alveoli are recruited and PEEP is
used to overcome LIP. However, recruitment is likely
to occur along the entire inflation in PV loop. An
upper inflection point on the pressure-volume curve is
thought to indicate overdistention13,14,15. However, the
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upper inflection point (UIP) might represent the end of
recruitment rather than the point of overdistention16.
Fig 6: PV loop is shown in comparison to PT scalar in volume
control ventilation. The inspiratory phase of the pressure-
volume curve consists of three sections. As the lung is inflated
from an initial low lung volume, the lung compliance is low.
As airway pressure is increased, lung compliance improves
(corresponding to LIP), which continues until the lung is fully
inflated. Inflating the lung further results in a reduction in the
lung compliance at the end of inflation as the lung over distends
(corresponding to pressure higher than HIP). The goal is to
ventilate in the safe window.
Hysteresis: It can be explained as lagging of one
of the two associated phenomena; that is, the two
fail to coincide or occur simultaneously. In the
non-diseased state, interaction of surfactant with
the elastic properties of the lung and chest wall
produces pulmonary hysteresis, which allows
for the maintenance of lung volume at lower
transpulmonary pressures during expiration than
are required during inspiration (fig 7). While in the
injured lung, hysteresis is less pronounced, and
the entire curve is displaced downward and to the
right, reflecting the higher pressures required to
achieve and maintain lung recruitment and an overall
decrease in lung compliance17,18. Hysteresis can also
explain theoretical advantage of few recruitment
maneuvers. One of the approaches use PEEP to
perform a recruitment maneuver (such as continuous
positive airway pressure of 40 cm H20 for 40 seconds
or the use of pressure control ventilation at a PEEP
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of 20-25 cm H20 with a driving pressure of 15-20
cm H20 for 1 -3 minutes) followed by a decremental
PEEP titration (starting at a high level of PEEP and
decreasing the PEEP stepwise while observing for
signs of de-recruitment). The intent of this approach
is to shift ventilation from the inflation limb to the
deflation limb of the pressure-volume curve19,20. This
result in a greater lung volume for the same applied
PEEP. While theoretically attractive, whether or not
it affects important patient outcomes is unclear.
Fig 7: Inflation and deflation in pressure volume loop illustrating
hysteresis.
Volume or pressure mode to interpret PV loop:
A number of studies have shown that PV loops
recorded during the course of ventilation correlate
well with loops from standard procedures, so long
as the inspiratory flow is constant. The studies are
based on the assumption that the drop in pressure
resulting from inspiratory resistances will also
remain constant at constant flow, and that the
steepness of the inspiratory loop will thus reflect only
the elastance of thorax and lung. Thus in ventilation
modes with decelerating flow (PCV etc.) it is not
possible to correctly draw conclusions from the PV
loop concerning the compliance of the lung (fig 8).
Fig 8: Dynamic pressure volume loop. Expiration waveform
is same in both. Only inspiratory waveform is different in the
two modes. i) Pressure control ventilation: Note the box-like
shape as here the pressure in the breathing system is kept at a
constant level (as operator set PIP) in inspiration ii) Volume
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control ventilation: here the flow is constant, allowing pressure
to change as per dynamics of system.
Dynamic PV loop in ARDS
In spite of enthusiasm for the use of PV loop to set the
ventilator in patients with acute respiratory distress
syndrome (ARDS), a number of issues preclude
routine use. Measurement of the PV loop requires
sedation, and often paralysis, for accuracy. It is often
difficult to identify the inflection points and may
require mathematical curves to precisely identify the
inflection points. Also, the PV loop treats the lungs as
a single compartment, but the lungs of patients with
ARDS are heterogeneous. This likely explains why
recruitment has been shown to occur along the entire
inflation in the PV loop21-24.
Volume Control Mode: PV loops display and analysis
As compliance decreases, in other words as the lung
becomes less elastic, and the ventilator settings remain
the same, the PV loop in volume-controlled ventilation
takes an increasingly flat course (fig 9, i). The change
in steepness of the inspiratory branch of the PV loop
is proportional to the change in lung25,26. If resistance
changes during constant flow ventilation the steepness
of the right branch of the loop remains unchanged, but
it becomes fatter due to inspiratory sag (fig 9, iii)
Fig 9. PV loop during volume-targeted ventilation. i) Low
compliance is denoted by a flatter loop because it takes a much
higher pressure to produce the same change in volume, ii)
Normal PV, iii) Increased airway resistance is shown as fatter
loop as increased flow-resistive work has resulted in the change
in inspiratory volume lagging behind the change in pressure. The
noticeable sag in the inspiratory curve has resulted in expansion
of the area that represents the inspiratory flow-resistive work
When overdistended, the lung is again noncompliant
and less accommodative of tidal volumes. As it
fills up, it increasingly stiffens, and so there is less
volume change for a given applied pressure toward
the end of the breath, than there is at the beginning of
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the breath. The flattening of the terminal part of the
inspiratory curve gives a characteristic beaked shape
to the PV loop (fig 10).
Fig 10. Pressure–volume loop: overdistension of the lung.
Pressure control mode: PV loop display and analysis
Assumptions cannot be made on the basis of this
loop about the course of lung compliance. When the
breathing gas flow is equal to zero at the start and
end of inspiration, however, the steepness of a line
drawn between the start of inspiration and the point
at the end of inspiration does represent a measure
of dynamic compliance (fig 11). This presupposes,
however, that flow equals zero both at the end of
inspiration and at the end of expiration.
Fig 11. PV loop during pressure-targeted ventilation. The
pressure is controlled at the preset value. With the deterioration
in lung compliance or increased resistance, the tidal volume falls
and the loop tilts downward and to the right.
4. Identify display images in common modes of
ventilation
a) Pressure Support Ventilation (PSV)
i) Flow time scalar: In PSV, as any pressure mode,
the ventilator delivers a high flow of gas to the
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patient when a breath is triggered. As the lungs
fill, the flow and the pressure gradient between the
machine and the patient decrease. The flow scalar
is descending but never decreases to zero during
inspiration because ventilators are programmed to
measure the drop in flow during inspiration until
it reaches a predetermined value. Some ventilators
end inspiration when flow drops to 25% of peak
flow during inspiration (fig 12). Most contemporary
ventilators provide flow cycling as an adjustable
parameter. This allows the operator to change the
cycle level (% peak flow) based on the type of
patient being ventilated.
ii) Pressure time scalar: PSV is a spontaneous mode
of ventilation, where patient’s respiratory activity
is augmented by delivery of a preset inspiratory
pressure. Tidal volume and flow delivery is variable,
depending on efforts and lung dynamics27 Concept
of rise time is essential to understand as explained
in fig 12. The rise time is the amount of time it takes
for the set pressure to be reached (B in fig 12, i). The
faster the rise in initial flow, the sooner the pressure
is reached but it should not overshoot. The slow rise
time, means slow flow, better comfort to patient.
Conversely if there is concavity in PT scalar, it
indicates that rise time is too slow, contributing to
increased work of breathing28.
Fig 12: Components of PS breath. i) Pressure Time (PT)
Scalar A, Trigger; B, Rise time, C, Pressure limit; D, Cycle. The
PS breath, if delivered ideally appears as a solid line. Patient
efforts and machine settings can affect the breath. A1, Incorrect
sensitivity or slow rise time; B1, slow rise time relative to patient
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demand. B2, rise time too fast causing overshoot; D1, pressure
spike caused by patient actively exhaling, D2 breath cycles early
because of early cycle criteria or B2. ii) Flow time (FT) scalar:
showing descending flow pattern and highlighting flow cycled
mode as cycling criteria is operator set (as in example shown
inspiration ends when flow rates decreases to set 25% of initial
respiratory flow).
iii) PV loop in pressure support mode
As all breaths are patient triggered, in PV loop
we see a small trigger tail. The larger the trigger
tail, the greater the patient effort, therefore greater
work (fig13).
Fig 13: Normal PV loop in pressure support breath, note the
baseline PEEP and inspiratory trigger.
b) Synchronized intermittent mandatory
ventilation (SIMV)
SIMV is a ventilator mode where mandatory
breaths are delivered intermittently with volume-
controlled or pressure controlled ventilation.
Between the mandatory breaths, the patient is
allowed to breathe spontaneously. The ventilator
delivers the mandatory breaths in synchrony with
the patient’s inspiratory effort (fig 14, breath 4).
If no inspiratory effort is detected; the ventilator
delivers a mandatory breath at the scheduled
time. This is usually achieved by use of an assist
window (fig 14). This window opens at intervals
determined by the SIMV rate, and remains open for
a manufacturer-specific period of time. If a patient-
generated effort is detected while this window is
open, a mandatory breath is delivered. If no patient
effort is detected in the time that the window is
open, the ventilator delivers a mandatory breath.
Also in the fig 14, the second breath (A) has
higher peak inspiratory flow, as patients demand
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may be high as compared to third breath where
his peak flow is low, as his demand may be low.
Else in breath 3 the volume may also be low due to
increased airway resistance; highlighting variable
flow and volume delivery in PSV mode.
Fig 14: SIMV (volume control) + PS mode: 1. Mandatory
Breath 2. PS breath (A) with high patient flow demand 3. PS
breath (B) with low patient flow demand 4. Assisted Mandatory
Breath
c) Airway pressure-release ventilation (APRV)
APRV mode uses long inflation periods (T High,
3-5 s) and short deflation periods ( T Low, 0.2-0.8
s), high pressure level, which is typically set at 20
to 30 cm H2O. This high pressure along with FiO2
determines oxygenation. Ventilation is determined
by the frequency with which the pressure releases
to the lower pressure, the difference between
the high pressure (P High) and the low pressure
(P Low), and the magnitude of spontaneous
breathing29. The low pressure setting is usually
0 to 5 cm H20. Spontaneous breathing can occur
at the high pressure and low pressure settings,
although the time at low pressure is usually too
short to allow spontaneous breathing (fig 15, i).
Various time ratios for high-to-low airway pressure
have been used with APRV, ranging from 1 : 1 to
9: 1. To sustain optimal recruitment, the greater
part of the total time cycle (80%-95%) should
occur at the high airway pressure. To minimize de-
recruitment, the time spent at low airway pressure
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(P Low) should be brief. As when the time at low
airway pressure is short, exhalation is incomplete
and alveolar recruitment due to auto-PEEP results.
Creating auto- PEEP is, by design, required with
the usual approach to APRV in which P low is set
to 0 cm H20. With this approach, the time at low
airway pressure is set such that the expiratory
flow reaches 50% to 75% of the peak expiratory
flow. Some ventilators allow the addition of PSV
to the spontaneous breaths during APRV (fig 15).
Spontaneous breathing during the high airway
pressure phase of APRV has the potential to
generate negative pleural pressures, which may add
to the alveolar stretch applied from the ventilator.
When PSV is triggered during the P high phase,
the higher baseline lung volume distends further
as the sum of P high, PSV, and pleural pressure
which overall raises transpulmonary pressure.
Furthermore, the imposition of PSV to APRV
may reduce the benefit of spontaneous breathing
by altering sinusoidal spontaneous breaths to
decelerating assisted mechanical breaths as flow
and pressure development may be uncoupled from
patient effort30.
Fig 15. Scalar events in airway pressure release ventilation.
i) Pressure time scalar: The P high is equivalent to a CPAP
level; Thigh is the duration of P high. The CPAP phase (P
high) is intermittently released to a P low for a brief duration
(T low) reestablishing the CPAP level on the subsequent breath.
Spontaneous or supported breathing may be superimposed
at both pressure levels and is independent of time-cycling. ii)
Flow time scalar: Expiratory flow pattern is important during
the release phase of airway pressure release ventilation. Initial
portion of expiratory flow limb is the peak expiratory flow rate
(PEFR) as a result of P high to P low pressure reduction. P low
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and T low regulate end expiratory lung volume and should be
optimized to reduce airway closure/ derecruitment and not as
a primary ventilation adjustment. Release time is adjusted to
regulate T-PEFR to 60% of PEFR, to create auto-PEEP and
prevent derecruitment. iii) Volume time scalar.
5. Interpret Expiratory Waveform and Flow
Volume Loops
A. Expiratory waveform
Expiratory flow is normally passive (it does
not require expiratory muscle activation) and is
determined by alveolar driving pressure, airways
resistance, the elapsed expiratory time, and the time
constant of the respiratory system. By convention,
expiratory flow is displayed on the flow-time graphic
in the negative direction and inspiratory flow is
displayed in the positive direction. The expiratory
waveform has two components: accelerating flow
(at start of expiration), and decelerating flow
(velocity slows as the lung empties to functional
residual capacity). The lowest negative point of
this waveform is peak expiratory flow (fig 16, i).
Fig 16: Flow time scalar. i) Normal constant flow, ii)
Obstructive airway disease, highlighting low PEF, concavity
and auto-PEEP.
Concept of dynamic hyperinflation and auto-PEEP:
In the presence of increased expiratory airflow
resistance the time available (expiratory time) to
empty the inspired volume may not be sufficient. The
next inspiration may start before the completion of the
expiration leading to air trapping. Thus the respiratory
system is unable to return to its normal relaxation
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volume at the end of expiration, leading to higher FRC
and thus, air trapping. This condition of air trapping is
otherwise called Dynamic hyperinflation (DHI). The
DHI results in positive alveolar pressure at the end of
expiration, referred to as auto-PEEP, occult PEEP or
intrinsic PEEP. Sometimes dynamic hyperinflation
and auto-PEEP can occur in the absence of airflow
limitation in mechanically intubated patients31. The
causes are usually due to rapid respiratory rate, high
tidal volumes, inspiratory time more than expiratory
time, small bore endotracheal and ventilatory tubes.
Although auto-PEEP and dynamic hyperinflation are
used synonymously, they actually differ. Auto-PEEP
may occur when strong expiratory muscle activity
is present, resulting in presence of flow at end of
expiratory cycle, causing auto-PEEP without actual
lung distention.
If auto-PEEP is present, the base line pressure will
rise to auto-PEEP. The end-expiratory occlusion
maneuver provides time to equilibrate lung units
that have different regional auto-PEEP, and the
value obtained after 2-3 seconds of end-expiratory
occlusion is the mean value after equilibration,
provided the airway is open and patient is relaxed
(as active expiratory muscle contraction can
elevate auto-PEEP without adding to dynamic
hyperinflation)32,33.
C) Flow-Volume loop: Fig. 18 shows a constant
flow–volume-targeted breath in dynamic
hyperinflation. The expiratory flow tracing fails to
return to the baseline at the end of exhalation.

Identification of auto-PEEP:
a) Flow time scalar: In flow time scalar airflow
obstruction can be identified. A part of the tidal
volume is “lost” and never delivered to the lungs
owing to high ventilating pressures (due to trapped
air). The lower PEF (fig 16, ii) illustrates the loss
of volume. The expiratory flow tracing adopts a
deeply curved contour (concavity downward), and
doesn’t touch the baseline, which points towards
air trapping or auto-PEEP. Fig 18: Flow–volume loop: i) normal and ii) auto – PEEP
b) Pressure time scalar: Performing an end- B. Flow – Volume loops
expiratory hold maneuver can identify it (fig 17). Flow-volume loops are displayed with flow as a function

Fig 17. Expiratory hold maneuver to estimate auto-PEEP. The valves are shut off at the end of expiration. When the flow equals zero
the pressure rises to the total PEEP level. Subtracting any external PEEP, if applied, from the total PEEP gives the value of auto-PEEP

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of volume. Some systems display expiratory flow in
the positive position, whereas other systems display
expiratory flow in the negative position. In this article,
expiratory flow is shown in the negative position.
During inspiration, the shape of the flow-volume loop
is determined by the flow setting on the ventilator with
volume-controlled ventilation. During exhalation,
the shape of the flow-volume loop is determined by
respiratory mechanics. In fig 19, the effect of changing
the mode on flow- volume loop is shown. The change is
noticed on set inspiratory flow settings while expiratory
being a passive function is same in all.
Fig 19. Flow–volume loop during volume controlled
ventilation. (a) Sine-wave flow pattern. (b) Square-wave flow
pattern in volume control ventilation. (c) Descending Ramp in
pressure control ventilation. (d) Descending Ramp in pressure
support ventilation. Note the abrupt decline in flow toward the
end of ventilation as the ventilator cycles from inspiration to
expiration (dotted circle)
Recognition of abnormal flow volume loops:
i) Obstructive and restrictive pattern
The shape of flow-volume loop guides us in
recognizing the flow defects in ventilation:
1. Extra-thoracic obstruction: The extra-thoracic
airways tend to collapse in inspiration, resulting
in reduced inspiratory flow, while exhalation is
normal (eg. Tracheal involvement above sterna
notch) (fig 20b)
2. Intra-thoracic obstruction: During exhalation
the transthoracic positive pressure is transmitted
to intra-thoracic narrowed segment, which
results in increased resistance to expiratory
flow, while inspiration is normal. (fig 20c )
3. Fixed upper airway obstruction: Here
flattening is seen in both phases of respiration.
(eg tracheal stenosis) (fig 20 d)
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4. Peripheral Obstructive airway disease:
In conditions like acute severe asthma,
understanding flow volume loop is essential.
The expiratory phase is divided into 3 parts: i)
PEF: peak expiratory flow is effort dependent
and is caused due to abrupt emptying of large
central airways that generate a brief period
of high flow and it becomes low in severe
diseases. ii) Concave downward slope: is
effort independent part of curve and is affected
in mild to moderate diseases. Here dynamic
compression of airways occurs. iii) The
expiratory flow doesn’t touch baseline, leading
to generation of intrinsic PEEP. (fig 20 e)
5. Restrictive ventilator defect: Here the lung in
unable to expand upto normal limits. The flow
volume loop has an outline similar to normal
loop but is reduced in size. (eg. Pulmonary
fibrosis) (fig 20 f)
Fig 20 : Flow volume loops. a) Normal loop, b) Extra thoracic
obstruction, c) Intra-thoracic obstruction, d) Fixed upper
airway obstruction, e) Peripheral Obstructive airway disease:
highlighting low PEF, concave downward slope and auto-PEEP,
f) Restrictive ventilator pattern
ii) Increased airway resistance: In Fig. 21,
a flow–volume loop obtained with PCV is
represented – note the decelerating waveform.
With increased airway resistance, tidal volumes
become constrained by the set airway pressures
(the inspiratory time is unchanged). Since flow is
volume divided by time, a decrease in flow will
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translate into lower tidal volumes if the inspiratory

time is unchanged.

Fig 21. Flow–volume loop: effect of increased airway

resistance on flow and volume in pressure control ventilation.
Shown in the panel on the left is a normal looking flow–volume
loop. The effect of increased airway resistance is shown in the
panel on the right. Both flow and volume have decreased

iii) Leak or volume loss
Volume loss: The expiratory tracing stops well
short of the y-axis – this can happen when
there is air leakage (circuit or ET cuff leak; or a
bronchopleural fistula), and a part of the inhaled
volume fails to return to the expiratory sensor.
Leak can also be identified by volume time (VT)
scalar and PV loop, where it produces a difference
between the inspiratory and expiratory tidal
volume in VT scalar and in PV loop, expiratory
limb doesn’t touch baseline34. (fig 22)
Fig 22. Leak in circuit: a) Flow–volume loop: lost tidal volume
or leak in circuit. b) Volume time scalar: Leak is highlighted by
arrow. c) PV loop: leak is marked by dotted circle.
iv) Airway Secretions: Secretions within the proximal
airway or the endotracheal (or tracheostomy)
tube can impart a saw toothed appearance to the
expiratory tracing (fig 23)

Fig 23: Effect of air secretions in flow–volume loop

6. Indentify signs of asynchrony

Asynchrony is the disharmony or ‘tug of war’
between the two interacting systems (ventilator
and neural respiratory drive of the patient). This
leads to deleterious effects: patient discomfort,
increased work of breathing, increased sedation
requirement and weaning failure. Asynchrony

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should be identified and understood well so

necessary interventions can be done to optimize
patient ventilator interaction.
Asynchrony can occur in various phases of the breath
cycle:
1. Trigger asynchrony: Improper interaction at
initiation of breath
2. Flow asynchrony: imbalance between ventilator
flow delivery and patient demand during inspiration
3. Cycling asynchrony: improper breath termination

TRIGGER ASYNCHRONY: This can be of 3 types:

1. Ineffective trigger
2. Double trigger
3. Auto trigger

1. Ineffective triggering: commonest type of trigger

asynchrony. This occurs when patient produces
respiratory muscular effort which is however
insufficient to initiate mechanical breath. This
leads to wasted patient work of breathing and may
result in respiratory fatigue35. Ineffective triggering
is manifested graphically as a decrease in airway
pressure associated with a simultaneous increase in
air flow (fig 24, 25)
Fig 24. Graphical display of pressure and flow trigger in
pressure support mode
Fig 25. Example of a missed or ineffective trigger during
pressure control ventilation. The arrow demonstrates the positive
flow deflection that is the hallmark sign of a missed trigger.
Factors responsible for ineffective triggering are:
a. Ventilator-related:
Insensitive trigger: Patient effort is unable to
reach the set trigger threshold (pressure or flow).
This can be corrected by reducing the threshold as
appropriate.
Inspiratory delay time: total time delay from the
initial patient effort until the pressure waveform
returns to baseline. Although flow triggering is
assumed to be more advantageous than pressure
triggering in this aspect, recent advances in
pressure transducers have resulted in comparable
results.
Resistance of artificial airway: larger pressure
drop occurs across a narrower ET or constricted
airways which requires higher patient effort to
overcome
b. Patient related:
- Inability to overcome effects auto-PEEP36
(Fig 26)
- Over sedation: decreased respiratory drive
- Respiratory muscle weakness

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Fig26 . Pressure-triggering in a patient with intrinsic positive end-expiratory pressure (PEEP). As an example, a patient has an
intrinsic PEEP of 6 cmH2O and inspiratory pressure trigger threshold is set at 2 cm H2O. i) ZERO PEEP, this graph shows a patient
with a set PEEP of zero and a trigger threshold of 2 cm H2O. However, this patient has an intrinsic PEEP level of 6 cm H2O. The
patient’s inspiratory effort would therefore have to generate a negative pressure of 8 cm H2O to trigger the ventilator, which is very
high and can cause missed trigger. ii) External PEEP, in this graph, the level of external PEEP is set at 4 cm H2O and the trigger
threshold is set 2 cm H2O below that level. The ventilator is triggered when the patient’s inspiratory effort reduces the airway pressure
to the set threshold level, which is 4 cm H2O, resulting in effective triggering.

2. Double triggering:
Double-triggering (also called breath stacking)
occurs when a patient’s inspiratory effort is strong
and continues throughout the preset ventilator
inspiratory time and remains present thereafter.
This patient’s inspiratory effort towards end of
tidal volume delivery triggers another breath.
Thus tidal volume is again delivered before
complete exhalation of the previous breath37.
Thus, the patient receives, in effect, a double
tidal volume, and is at risk of lung over-inflation.
Double triggering can be caused by aggressive
patient efforts in conjunction with small VT and
short inspiratory times. During PSV with a high
flow termination criterion, double triggering is
also possible (fig 27).
Fig. 27. An example of double triggering in pressure support
ventilation. Patient demand continues beyond the set inspiratory
time, resulting in triggering of a second mandatory breath during
the same patient effort.

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3. Auto-triggering:
Auto-triggering occurs when the ventilator
delivers an assisted breath that was not initiated
by the patient. Auto-triggering may also be due to
expiratory leak, water or noise in circuit, cardiac
oscillations or inappropriately sensitive triggering
thresholds. It needs to be corrected by careful
adjustment of trigger sensitivity
Fig 29: Pressure time scalar in volume breath i) Flow
asynchrony – early dip due to patient effort or low set flows ii)
4. Reverse triggering:
Volume starvation is noted in terminal part.
Akoumianaki and colleagues have recently
described “reverse triggering” as a unique type
of neuromechanical asynchrony38. Diaphragmatic
muscle contractions triggered by ventilator
insufflations constitute a form of patient-ventilator
interaction referred to as “entrainment”. In heavily
sedated patients it is suggested that patients had
entrainment of neural breaths within mandatory
breaths. This entrainment occurred at a ratio of
1:1 up to 1:3. They occur at the transition from Fig 30. Pressure–volume loop: flow starvation.
the ventilator inspiration to expiration. Of concern
is that, reverse triggering can result in breath Flow vs pressure targeted ventilation: In flow-
stacking and overdistention and may play a role targeted breaths the clinician chooses the speed and
in ventilator induced diaphragmatic dysfunction pattern of the flow (constant/descending ramp etc).
Peak flow delivery will depend on flow pattern. As
Flow asynchrony volume control breaths have preset flow parameters
This occurs when the ventilator flow does not (both peak flow and flow pattern); flow asynchrony is
match the patient flow (either too fast or slow or bound to occur if set parameters do not match patient
inadequate). This type of asynchrony is also common demand. Descending ramp flow with its high initial
and may occur with either flow or pressure targeted peak flow may be better suited to patient’s increased
ventilation. During assisted ventilation, in order to demand. In a pressure-targeted breath the speed at
unload respiratory muscles, a patient should not have which the targeted pressure (set by clinician) is
excessive WOB. Ideally the amount of work done by reached depends on rise time. Faster rise time leads
the patient should be just enough to trigger ventilator. to higher flow to achieve set pressure faster. Pressure
However in reality respiratory muscles continue to targeted breaths have variable flows and hence are
contract even after ventilator is triggered. Hence it better able to match patient’s needs.
is important to synchronize ventilator flow delivery
with the patient to limit WOB and avoid respiratory Rise Time: In descending ramp, flow waveform
muscle fatigue. Flow asynchrony can be identified on should smoothly reach up to peak flow and decrease
the pressure-time scalar which reveals a dip (scooped gradually thereafter. If flow is faster than patient’s
out appearance) during assisted inspiration (fig demand, there will be peaking (pressure spike/
29). This occurs when the ventilator flow is below overshoot) at the start of inspiration on the pressure-
the patient’s desired flow, and the patient “pulls time scalar. In pressure targeted ventilation, rise
down” the pressure-time waveform and can also be time should be appropriately adjusted. It is normally
visualized in PV loop (fig 30). kept < 0.2 seconds. Too short rise time will lead to
pressure overshoot (fig 31).

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Fig 31: Rise Time: Slow, moderate and fast rise are depicted.
Fast rise (due to short rise time) leads to pressure overshoot.
On the flow time scalar, pressure relief is seen due to active
exhalation valve.
Cycling Asynchrony:
Cycling is the termination of inspiration by ventilator
and switch to expiration. When there is a mismatch
between the timing of ventilator and patient with
respect to termination of inspiration it leads to
cycling asynchrony. This is of 2 types:
Delayed cycling: When ventilator continues
its inspiratory flow although patient has begun
expiratory effort. This leads to a pressure spike at end
of ventilator assisted inspiration and rapid decrease
in flow (fig 32). Active patient exhalation can also
be observed by palpation of the patient’s abdomen.
Delayed cycling leads to insufficient expiratory time,
air-trapping, and subsequent failure of triggering. It
should be corrected by decreasing inspiratory time
and/or tidal volume. For patients who have variable
inspiratory times, switching to pressure support may
be considered due to flow cycling.
Fig 32: Delayed cycling leading to pressure spike marked by
A. Subsequent ineffective trigger (IT) is also seen.
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Premature cycling: Premature cycling is present
when a patient is continuing to inhale after ventilator-
assisted inspiration has terminated. This is seen on
pressure time scalar as a decrease in airway pressure
at end of inspiration. Flow time scalar will show an
increase in air flow immediately after inspiration (fig
33). The timing of this event (just after inspiration)
differentiates it from ineffective triggering.
Fig 33: Premature cycling seen as a negative dip below PEEP on
pressure scalar (A). Simultaneous increase in flow is also seen (B)
Pressure support: cycle asynchrony
During PSV, the ventilator is normally flow-cycled at
a fraction of the peak flow. Secondary cycle criteria
are pressure (if the pressure exceeds the pressure
support target) and time (if the inspiratory phase
is prolonged). The inspiratory time during PSV is
determined by lung mechanics and the flow cycle
criteria39. With decreased compliance, the flow cycle
is reached earlier in the inspiratory phase, and the
result is early inspiratory termination and the potential
for double triggering (fig 27). With an increased
compliance and increased resistance, as occurs with
asthma, there is a slow descent in flow, meaning that
the flow cycle criteria will be reached later and the
inspiratory phase will be prolonged. Prolongation
of the inspiratory phase can result in air-trapping
and dynamic hyperinflation. This can also result
in activation of the expiratory muscles, which can
be detected clinically by palpation of the patient’s
abdomen or observing the pressure waveform for a
pressure increase at the end of the inspiratory phase
(Figure 32). Prolonged inspiration causing cycle
asynchrony during PSV can be corrected by lowering
the pressure support level or by an increase in the
termination criteria of the flow setting.
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SYMPOSIUM: PULMONARY CRITICAL CARE
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