Ventilator Waveforms:

Basic Interpretation and

Analysis
Vivek Iyer MD, MPH
Steven Holets, RRT CCRA
Rolf Hubmayr, MD

Edited for ATS by:

Cameron Dezfulian, MD
 Outline of this presentation
• Goal:
– To provide an introduction to the concept of ventilator
waveform analysis in an interactive fashion.
• Content:
– Outline of types of ventilatory waveforms.
– Introduction to respiratory mechanics and the
‘Equation Of Motion’ for the respiratory system
– Development of the concept of ventilator waveforms
– Illustrations and videos of waveforms to illustrate their
practical applications and usefulness.
 Types of Ventilator Waveforms:
Scalars and Loops
Scalars are waveform representations of pressure, flow or volume on the y axis vs
time on the x axis

flow vs time
scalar

Inspiratory
arm

expiratory
arm

pressure vs time
scalar

volume vs time
scalar
 Types of Ventilator Waveforms:
Scalars and Loops
Loops are representations of pressure vs volume or flow vs volume
Expiratory
arm

Pressure Vs volume
loop

volume
pressure
Inspiratory
arm

Flow Vs volume
loop
Expiratory
flow

arm

volume
Understanding the flow-time waveform
• There are two components to the flow-time
waveform
– The inspiratory arm:
• Active in nature
• The character is determined by the ventilatory flow settings.
– The expiratory arm:
• Passive in nature
• The character is determined mainly by elastic recoil of the patients
lungs and airway resistance.
• Also affected by patient respiratory effort (if any)

• There are two commonly used types of flow

patterns available on most ventilators
– The ‘square wave’ or ‘constant flow’ pattern
– The ‘ramp’ (decelerating) type pattern
 The ‘square wave’ flow pattern

The inspiratory flow rate

remains constant over Inspiratory
the entire inspiration. arm

flow

The expiratory flow is

passive and is
determined by airways time
resistance and the
elastic recoil of the lungs

Expiratory
Inspiratory time = Tidal volume arm
Flow rate
 The ‘decelerating ramp’ flow pattern
The inspiratory flow rate
decelerates as a function
Inspiratory
of time to reach zero flow
arm
at end inspiration

flow

For a given tidal volume,

the inspiratory time is
higher in this type of flow
pattern as compared to time
the square wave pattern

Expiratory
Inspiratory time = Tidal volume arm
Flow rate
Now let us try to understand the
following in the next few slides

•A basic ventilator circuit diagram

•Airway pressures
•The equation of motion for the
respiratory system
•The pressure-time waveform
 Understanding the basic
ventilator circuit diagram

ventilator

Essentially
The ventilatorthe circuitup
makes diagram
the firstofpart
a
mechanically
The circuit.ventilated
patient’s
of the own patient
respiratory
Its pump canisbe
system
like action ET Tube
broken
depicted
Makes down
the 2ndinto
up simplistically
parttwo
ofasparts…..
a piston
the circuit. airways
These
that two systems
Themoves are connected
in a reciprocating
diaphragm is also as aby
shownfashion
2an endotracheal
duringcausing
nd piston; tube
the respiratorywhich
air to we can
becycle.
drawn into
consider as an extension
the lungs during contraction. of the
patients airways.

Chest wall Diaphragm

 Understanding airway pressures
The respiratory system can be thought of as a mechanical
system consisting of a resistive (airways) and elastic
(lungs and chest wall) element in series

ET Tube
PLungs= + Chest
Flow wall
Resistance + Volume Paw
THUS Airways
aw
(elastic element) Compliance Airway pressure
(resistive element) airways

Airways Lungs + Chest wall

The contribution of the elastic element
(resistive
(lungs element)
+ chest
The contribution depends on (elastic
wall) resistance
of airway element)
pressurethe degreeonofthe
depends lung inflation
rate and
of airflow
and thethe underlying
underlying compliance
resistance of the
(caliber)
lungs
of theand the chest wall
airways
PPL
Pleural pressure

Chest wall

Flow resistance
Volume Diaphragm
compliance

Palv
Alveolar pressure
 Understanding basic respiratory mechanics

Thus the equation of motion for the respiratory system ventilator

is

P applied (t) = Pres (t) + Pel (t)E

RET
lungs
tube ET Tube
Raw
Ers airways

Rairways
Echest wall
Thus to move
The total air into
‘elastic’ the lungs
resistance (Eat a given time (t),
rs) offered by the
The total ‘airway’ to the(R
resistance (P) of
the ventilator
respiratory hassystem
to generate
is equala pressure aw
sum applied) Diaphragm
Let us now
in theunderstand
that is sufficient mechanically how the respiratory
ventilated patient systems’
elasticto overcome offered
resistances the pressure
by thegenerated
inherent
is equal elastance
to the sum and
of theresistance
resistancesto airflow
offered
by the elastic (PLung el (t)) Eand airway
and (P
theaw ) resistances
lungs generated within a
determines the pressures (R ET
offeredby the
by theendotracheal
respiratory
chest wall
tube
system
E chest tube)time.
at that
mechanically ventilated
and the patient’s airways ( R airways) system.
wall
 Understanding the pressure-time waveform
using a ‘square wave’ flow pattern
Ppeak
pressure

Pres

ventilator
Pplat
Pres
RET tube
time
Pres

Rairways

After this, the pressure rises in a linear fashion

toThe
At
finally
the
pressure-time
beginning
reach Ppeakof waveform
. Again
the inspiratory
at end
is a reflection
inspiration,
cycle, Diaphragm
the
air of
ventilator
flow
theispressures
zero
hasandto the
generate
generated
pressure
a within
pressure
dropsthebyPan
res
amount
to
airways
overcome
equal
during
to the
Pres
each
airway
to reach
phase
resistance.
the
of the
plateau
Note:
pressure
No volume
Pventilatory
plat. The
is delivered
pressure
cycle. atreturns
this time.
to
baseline during passive expiration
 Now let’s look at some different pressure-time
waveforms using a ‘square wave’ flow pattern
Paw = Flow Resistance + Volume
Compliance

Scenario # 1
pressure

Ppeak
Normal values:
Pres Ppeak < 40 cm H2O
Pplat < 30 cm H2O
Pres < 10 cm H2O
Pplat
Pres

flow
time

This is a normal pressure-time waveform time

With normal peak pressures ( Ppeak) ;
plateau pressures (Pplat )and
‘Square wave’
airway resistance pressures (Pres) flow pattern
 Waveform showing increased airways resistance

Paw = Flow Resistance + Volume + PEEP

Compliance

Scenario # 2
pressure

Ppeak Normal
e.g. ET tube
Pres blockage

Pplat
Pres

flow
time

The increase in the peak airway pressure is driven time

entirely
This isby
anan
abnormal
increasepressure-time
in the airwayswaveform
resistance
pressure. Note the normal plateau pressure. ‘Square wave’
flow pattern
 Waveform showing increased airways resistance

‘Square
wave’ flow
pattern

Ppeak

Pplat

Pres
 Waveform showing high airway resistance
due to high flow rates
Paw = Flow Resistance + Volume + PEEP
Compliance
Scenario # 3
pressure

Ppeak Normal
e.g. high flow
Pres rates

Pplat

Pres

time

flow
The increase in the peak airway pressure is driven time
Normal (low)
entirely by abnormal
This is an an increase in the airways
pressure-time resistance
waveform flow rate
pressure caused by excessive flow rates.
‘Square wave’
Note the shortened inspiratory time and high flow flow pattern
 Waveform showing decreased lung compliance

Paw = Flow Resistance + Volume + PEEP

Compliance
Scenario # 4
pressure

Ppeak Normal
e.g. ARDS
Pres

Pplat

Pres

flow
time
The increase in the peak airway pressure is driven
entirely by the decrease in the lung compliance. time
This is an abnormal
Increased airways pressure-time waveform
resistance is often
also a part of this scenario. ‘Square wave’
flow pattern
 Waveform showing decreased lung compliance

‘Square
wave’ flow
pattern

Ppeak

Pplat

Pres
 Now lets look at the same pressure-time tracings
using a ‘decelerating ramp’ flow pattern

Normal High Raw:

High
(e.g. asthma)
Normal PIP
PIP

Normal Normal
Pplat Pplat
pressure

High flow: High

High
(Note short
PIP Low CL:
PIP
Inspiratory e.g.
time) ARDS

High
Normal Pplat
Pplat

time
 Now let us try to understand
the practical aspects of
ventilator waveform analysis in
an interactive fashion.
 Clinical applications of ventilator
waveform analysis
• Ventilator waveforms can be very useful in many
different situations including:
– Diagnosing a ventilator that is ‘alarming’
– Detecting obstructive flow patterns on the ventilator
– Detecting air trapping and dynamic hyperinflation
– Detecting lung overdistention
– Detecting respiratory circuit secretion build-up
– Detecting patient-ventilator interactions
• Dyssynchrony
• Double triggering
• Wasted efforts
• Flow starvation
Some ventilators with waveform displays

Puritan Bennett 840 Puritan Bennett 7200 Dräger Evita XL

Siemens Servo 300A Bear 1000 series Respironics Esprit

 Waveform selection on different ventilators

PB 840
Ventilator
Select different
waveforms

Size
adjustment

Time scale

Push to start
waveforms
Waveform selection on different ventilators

Respironics
Espirit
ventilator

Push to select
waveforms
Waveform selection on different ventilators

Switch between
waveforms

Respironics
Espirit
ventilator

Press to
adjust size

Switch between
Loops and scalars
 Variables that govern how a ventilator
functions and interacts with the patient
Control variable
‘The Mode of Ventilation’
Pressure, flow, or volume
controlled

Limit Variable
Volume, pressure or flow
can be set to be constant
or reach a maximum

Triggering variable
pressure, flow or volume
sensing that initiates
the vent cycle

Cycle variable
Pressure, volume, flow,
or time that ends the
inspiratory phase
So what waveforms should I
be observing and analyzing?

Look at the waveforms that are

varying based on the settings you
have ordered
 Mode of ventilation -> useful waveforms
Mode of Independent Dependent Waveforms that will Waveforms that
ventilation variables variables be useful normally
remain
unchanged
Volume Tidal volume, Paw Pressure-time:-> Volume-time
Control/ RR, Flow rate, changes in Pip, Pplat Flow time
Assist- PEEP, I/E ratio Flow-time (expiratory): - (inspiratory)
Control >changes in compliance Flow-volume loop
Pressure-volume loop:->
overdistension, optimal
PEEP
Pressure Paw, Inspiratory Vt, flow Volume-time and flow- Pressure-time
Control time (RR), time: -> changes in Vt and
PEEP and I/E compliance
ratio Pressure-volume loop:->
overdistension, optimal
PEEP

Pressure PS and PEEP Vt,and RR, Volume- time

support/ Flow- time
flow, I/E
CPAP (for Vt and VE)
Ratio

Vt=tidal volume; RR=respiratory rate; Paw=airway pressure; PEEP= positive end expiratory pressure; I/E ratio= inspiratory/expiratory time;

VE= minute ventilation; Pip = Peak inspiratory pressure; Pplat = Plateau pressure
 Waveforms to observe during volume
assist control ventilation

• Pressure-time waveform:
– Affected by patient effort and changes in
resistance and compliance
• Flow-time waveform:
– Expiratory flow is not fixed, waveform is
dependent on elastic recoil pressure of
respiratory system/patient effort
– Therefore this scalar is nearly always of
interest
Waveforms to observe during pressure
targeted ventilation: PCV

• Pressure-time waveform usually will not

change
• Flow-time and volume-time waveform
will be affected by changes in
compliance, resistance and the patient’s
respiratory muscle strength
(independent variables)
Now let us begin riding the
‘waves’ by looking at a few
ventilator waveforms!
 Basic ventilator waveforms

Mode of ventilation: Assist/control – square

wave flow

– Airway pressures: dependent on lung compliance, tidal volume

and flow (dependent variable)
– Tidal volumes, respiratory rate: ventilator controlled
– Flow pattern: ventilator controlled (square wave pattern)
– Inspiratory time: ventilator controlled
– Waveforms shown: flow-time and pressure-time
 Square wave volume assist/control mode

Any abnormalities? : No
PEARL: always look at both inspiratory and expiratory arms
of the flow-time waveform. Make it a habit!
 Basic ventilator waveforms

Mode of ventilation: Assist/control –

decelerating flow pattern
– Airway pressures: dependent on lung compliance, tidal volume
and flow (dependent variable)
– Tidal volumes, respiratory rate: ventilator controlled
– Flow pattern: ventilator controlled (decelerating wave
pattern)
– Inspiratory time: ventilator controlled
– Waveforms shown: flow-time and pressure-time
Decelerating flow volume assist/control mode

Any abnormalities? : No
PEARL: At similar flow rates, the inspiratory time is shorter (and
peak pressures higher) for the square wave flow as compared to the
decelerating flow pattern.
 Basic ventilator waveforms

Mode of ventilation: CPAP + PS

– Airway pressures: patient controlled (indirectly

through control of volume and flow)
– Flow pattern: patient controlled
– Inspiratory time, respiratory rate: patient controlled
– Waveforms shown: flow-time and volume-time
 CPAP with Pressure Support

Any abnormalities?: No
PEARL: notice how each breath differs in flow pattern and
tidal volume.
 Basic ventilator waveforms

Mode of ventilation: pressure control ventilation (PCV)

– Airway pressures: ventilator controlled

– Respiratory rate: ventilator controlled
– Tidal Volumes: dependent variable (lung compliance)
– Flow rates: ventilator controlled (decelerating in this instance)
– Waveforms shown: flow-time and volume-time
 Pressure Assist/Control – Decelerating Flow

Any abnormalities? : No
PEARL: tidal volumes and flow rates are determined by lung
compliance. Increasing inspiratory time beyond a certain point will
only decrease expiratory time, without any increases in tidal volumes
achieved.
 Let us now shift gears and see how
waveforms can help us recognize some
common ventilator related problems!

Common problems
that can be diagnosed
by analyzing
Ventilator waveforms

Patient-ventilator
Abnormal ventilatory Ventilatory circuit related
Interactions
Parameters/lung mechanics problems
E.g. flow starvation,
E.g.. Overdistension, E.g. auto cycling and
Double triggering,
Auto PEEP Secretion build up in the
Wasted efforts
COPD Ventilatory circuit
Active expiration
 Now let us learn to recognize
Lung overdistension
and the development of
Auto PEEP

Patient-ventilator
Abnormal ventilatory Ventilatory circuit related
Interactions
Parameters/lung mechanics problems
E.g. flow starvation,
E.g.. Overdistension, E.g. auto cycling and
Double triggering,
Auto PEEP Secretion build up in the
Wasted efforts
COPD Ventilatory circuit
Active expiration
 Let us briefly revisit the flow-time
waveform

• As previously noted, the flow-time waveform has both an inspiratory and an

expiratory arm.

• The expiratory arm is passive in nature and its character is determined by:
– the elastic recoil of the lungs
– the airways resistance
– and any respiratory muscle effort made by the patient during expiration (due to
patient-ventilator interaction/dys=synchrony)

• The expiratory arm can be thought of in some ways as passive bedside

spirometry.

• It should always be looked at as part of any waveform analysis and can be

diagnostic of various conditions like COPD, auto-PEEP, wasted efforts,
overdistention etc.
 Recognizing
Lung
Overdistension
 Recognizing lung overdistension
Suspect this when:

There are high peak and plateau

Pressures…

Accompanied by high expiratory

Flow rates

The pressure-time waveform

Shows an abrupt increase in
Pressure.

PEARL: Think of right mainstem intubation,

low lung compliance (e.g. ARDS),
excessive tidal volumes etc
The pressure-volume loop can tell us a
lot about lung physiology!
Compliance (C)
is markedly reduced in the
injured lung on the right as
compared
Normal to the normal lung
lung on the left

Upper inflection point (UIP)

above this pressure,
additional alveolar recruitment
requires disproportionate
increases
ARDS in applied airway pressure

Lower inflection point (LIP)

Can be thought of as the
minimum
baseline pressure (PEEP)
needed for optimal
alveolar recruitment
Observe a pressure-volume loop illustrating
the concept of overdistension

Peak
Inspiratory
pressure

Upper
Inflection
point

Lower
Inflection
point
Lung overdistension based
on pressure-volume loops
Recognizing
Auto-PEEP
 Detecting Auto-PEEP

Recognize
Auto-PEEP
when

Expiratory flow continues

and fails to return to
the baseline prior to the new
inspiratory cycle
 The development of auto- PEEP over
several breaths in a simulation

Notice how the expiratory flow fails

to return to the baseline causing
progressive air trapping

Also notice how the progressive

air trapping causes a gradual
increase in airway pressures
due to decreasing compliance
Development of auto-PEEP

Notice how the expiratory

flow fails to return to
the baseline causing
progressive air trapping

Click here to watch video

Also notice how the

progressive air trapping
causes a gradual
increase in airway
pressures because of
decreasing compliance
 Understanding how flow rates affect I/E
ratios and the development of auto PEEP

Decreasing the flow rate

Increase the inspiratory time

and consequently decrease the
expiratory time
(decreased I/E ratio)

Thus allowing only incomplete emptying

of the lung and the development
of air trapping and auto-PEEP

Lluis Blanch MD, PhD et al: Respiratory Care Jan 2005 Vol 50 No 1
 Understanding how inspiratory time affect I/E
ratios and the development of auto-PEEP

• In a similar fashion, an increase in inspiratory time can

also cause a decrease in the I: E ratio and favor the
development of auto-PEEP by not allowing enough time
for complete lung emptying between breaths.

• Watch in the next video how auto-PEEP develops in a

patient on Pressure control ventilation at a RR of 20, just
by increasing the inspiratory time from 0.85 sec to 1.0
sec (no auto-PEEP develops) and then to 1.5 sec
(development of auto PEEP)
 Ventilator settings before and after the
development of auto-PEEP
Mode of ventilation: PCV ( pressure control ventilation)
– Waveforms depicted: flow-time and pressure-time
– Pressure support: 15cm/H2O with PEEP of 5 cm/H2O
– Respiratory rate: 20 bpm

Ventilator Initial Subsequently Final

settings settings settings
Inspiratory 0.85 sec 1.0 sec 1.5 sec
time
Expiratory 2.15 sec 2.0 sec 1.5 sec
time
I : E ratio 1 : 2.5 1: 2 1: 1
Auto PEEP No No Yes
Development of auto-PEEP with
inadequate expiratory time

Click here to watch video

 Recognizing Expiratory Flow
Limitation (e.g. COPD, asthma)
 Recognizing prolonged expiration (air trapping)

Recognize
Airway obstruction
when

Expiratory flow quickly tapers off

and then enters a prolonged
low-flow state without returning to
baseline (auto- PEEP)

This is classic for the flow

limitation and decreased lung
elastance characteristic of COPD
or status asthmaticus
 Let us now move forward and
Learn about diagnosing
patient-ventilator Interactions
by analyzing ventilator
waveforms

Patient-ventilator
Abnormal ventilatory Ventilatory circuit related
Interactions
Parameters/lung mechanics problems
E.g. flow starvation,
E.g.. Overdistension, E.g. auto cycling and
Double triggering,
Auto PEEP secretion build up in the
Wasted efforts
COPD Ventilatory circuit
Active expiration
 Recognizing:
Wasted efforts
Double triggering
Flow starvation
Active expiration
Recognizing ineffective/wasted patient effort

Patient inspiratory effort

fails to trigger vent cycle
resulting in a wasted effort

Results in fatigue, tachycardia,

Increased metabolic needs,
Fever etc
 Recognizing double triggering
High peak airway
pressures and
double the inspiratory
volume

Continued patient inspiratory efforts

through the end of a delivered
breath cause the ventilator to cycle again
and deliver a 2nd breath on top of the
first breath that has still not been completely
exhaled.
This results in high lung volumes and
pressures.

Consider switching mode,

increasing sedation, or
neuromuscular paralysis
as appropriate
Another example of double triggering
 Recognizing flow starvation

Look at the pressure-time

waveform

If you see this kind of

scooping or distortion instead
of a smooth rise in the
pressure curve….

Diagnose flow starvation

in the setting of patient
discomfort, fatigue,
dyspnea etc on the vent
 Recognizing active expiration

Look at the flow-time

& pressure-time
Waveform

In this situation, the patient is

making active expiratory efforts
during the inspiratory
phase of the ventilator delivered
breath cycle

Notice how the expiratory

flow and the pressure rise
dramatically as a result
of the opposing forces at
work
 Lastly let us learn to recognize
Ventilatory circuit related
problems by analyzing
ventilatory waveforms

Abnormal ventilatory Patient-ventilator

Ventilatory circuit related
Parameters/lung mechanics Interactions
problems
E.g.. Overdistension, E.g. flow starvation,
E.g. auto cycling and
Auto PEEP Double triggering,
secretion build up in the
COPD Wasted efforts
Ventilatory circuit
 Recognizing
Airway Secretions
&
Ventilator Auto-Cycling
Recognizing airway or tubing secretions

Flow volume loop

Normal flow-volume showing a ‘saw tooth’
loop pattern typical of
retained secretions
Characteristic scalars due to secretion
build up in the tubing circuit
Recognizing ventilator auto-cycling
• Think about auto-cycling when the respiratory rate increases
suddenly without any patient input and if the exhaled tidal
volume and minute ventilation suddenly decrease.
• Typically occurs because of a leak anywhere in the system
starting from the ventilator right up to the patients lungs
– e.g. leaks in the circuit, ET tube cuff leak, lungs
(pneumothorax)
• May also result from condensate in the circuit
• The exhaled tidal volume will be lower than the set
parameters and this may set off a ventilator alarm for low
exhaled tidal volume, low minute ventilation, circuit disconnect
or rapid respiratory rate.
 Waveform video showing
the ventilator ‘auto cycling’

Click here to watch video

 Take home points

• Ventilator waveform analysis is a very integral

and important component in the management of
a mechanically ventilated patient.
• Develop a habit of looking at the right waveform
for the given mode that the patient is being
ventilated on.
• Always look at the inspiratory and expiratory
components of the flow-time waveform.
• Don’t hesitate to change the scale or speed of
the waveform to aid in your interpretation.
 Additional links
• Follow these links for more waveform videos:
– Auto-PEEP
http://www.youtube.com/watch?v=30jdXd7TS84
– Autocycling
http://www.youtube.com/user/dakaufman123#p/a/u/0/
CPOsp8WJSrA
– Excessive airway secretions:
http://www.youtube.com/user/dakaufman123#p/a/u/1/
F93mPDMtl8I
– Flow starvation
http://www.youtube.com/user/dakaufman123#p/a/u/2/
ZoyFcvNqVq0