Understanding Ventilator Curves - Drager

Graphics in Neonatal
Ventilation
06/20/21/Dateinamen/Autor
Airway Monitoring
1. Diagnostics and Quantification

(RDS, BPD, aspiration syndrom ...)
2. Therapy Decisions
(Indication for ventilatory support, surfactant,
apnoea therapy ...)
3. Optimizing Ventilator Settings

Airway Monitoring
Pressure
Flow
Volume
Lung mechanics
Pressure
The driving force for all modes of ventilation commonly

used with neonates.
Basic monitoring on neonatal ventilators should include
 Peak pressure
 Mean airway pressure
 Positive end expiratory pressure

Pressure Measurement
The Pressure Wave

Peak Pressure
Mean Pressure
PEEP
Quasi Static Dynamics of pressure

Measurements Interaction of ventilator and
patient
Problems related to pressure measurement hoses
 kinking
 loose connections
 condensation
 an extra tube to manage

Pressure Wave
The Babylog 8000 Pressure Measurements Screen
Parameters used to adjust Airway Pressure
Pinsp PEEP/CPAP Insp. Flow
Standard controls used to Can be used to attain:

adjust airway pressure  PIP
 Shape of Pressure Wave
 I:E ratios
 Respiratory Rate
Setting Lower Flow Rates
Effect on delivered breath Clinical Effect
Slower increase in airway pressure  flow into patient is more like a

spontaneous breath
Sloping pressure wave form
 if Ti not long enough, VT may be
impaired, potential  PaC02
 Lower MAP thus potential  Pa02
 Theorectically less barotrauma

Setting Higher Flow Rates
Effect on delivered breath Clinical Effect
 May help open up atelectatic alveoli and

therefore improve gas distribution.
 May impede venous return
 Higher MAP thus potential Pa02
 Immediate increase in
airway pressure
 PIP reached early in the

Ti. Longer time spent at
Peak Pressure
 High initial flow rate into

patient. VT delivered early
in the Ti.
Five different ways to increase MAP
Changes in Compliance during Pressure Limited Ventilation
m bar Paw
P in s p
cL
cL
PEEP
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
As a result of change in compliance, the pressure rise time of the

pressure wave will change
• increase in compliance decrease in pressure rise time

• decrease in compliance increase in pressure rise time
Adjusting flow rate will alter MAP
without effecting ventilation
Mean Airway Pressure Trend
PiP and PEEP Measurements
PiP
 The maximum pressure measured
during the last completed ventilatory
cycle.
PEEP or CPAP
 The baseline pressure.
 Controls Functional Residual

Capacity.
Adjusting Flow Rate
Increase flow rate if Decrease flow rate if
 Pressure rise time is too quick
 Pressure rise time is too slow  A pressure plateau occurs but

is but not wanted.
 A plateau is desired but pressure

does not reach the pressure limit.
 flow is insufficient to meet

spontaneous demand
Spontaneous Breaths
Conclusion
 Pressure waves do provide a lot of information about patient and ventilator

interaction.
 However pressure is only the driving force for flow and volume.
 Detailed feedback on the patients pulmonary status requires assessment of

flow wave forms and volume measurements.
Lung Mechanics
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Minute Ventilation
MV
MV = f * VT
Ti
Vt f
Te
Tidal Volume
PEEP PiP
P
Ti
Vinsp Vt
Te
rs
Rrs Crs
Placement of a Neonatal Flow Sensor
Tubing System
.
V
Ct
Respiratory
System
Crs
How the Babylog Detects Flow Direction
Hot wire 2
Hot wire 1 Shade
exp.
Flow Direction
insp.
Very low flow

insp.
Measurement Conditions
NTPD versus BTPS
p*NTPD:
 Normal Temperature (20°C)
V
 Normal Pressure (1013 mbar)
 Dry Gases (0% rel.humidity)
BTPS:

=
Body Temperature (37°C)
m
 Body Pressure (ambient pressure + MAP)
 Saturated Gases (100% rel.humidity)
*R
Babylog 8000 BTPS conditions
(Conditions at Y-piece):
*T
 Calibration temperature 25°C
 Measurement temperature 35°C
 Relative humidity 90% at 35°C
 Pressure 1023 mbar

How do we interpret the Flow Wave ?
Set Inspiration Time Set Expiration Time

Ti Te
Peak
Inspiratory
Flow Expiratory
Flow begins
Inspiratory
Flow begins Expiratory Flow returns
Inspiratory Flow returns
to 0 as lung inflation is to 0 as lung deflation is
completed. completed. Lung remains
Lung remains inflated deflated for remainder of Te.
for remainder of Ti.
Peak Expiratory Flow

Flow Curve during Pressure Limited Ventilation
Timing and the Flow Wave
Flow
Te
Inspiratory
Flow Le
0
Li Time
Expiratory Ti Start of next Inspiration
Flow
Li = Time lung takes to inflate. Le = Time lung takes to deflate.

Inspiratory Flow occurs during this time. Expiratory flow occurs during this time.
Ti = Inspiratory time set on ventilator. Te = Expiratory time set on ventilator.
To avoid gas trapping Te should be

set longer than Le.
How can we Recognise Compromise of Inspiratory Flow ?
Flow
Inspiration
Incomplete
Inspiratory
Flow
Te
0
Li Time
Expiratory Ti
Flow
Li = Time lung takes to inflate. Ti < Li

Ti is too short. Increase Ti to allow time
Ti = Inspiratory time set on ventilator. for lung inflation to complete.
Te = Expiratory time set on ventilator.

Flow Curve during insufficient Inspiration Time
L/min Flow
Inspiration flow does
not return to zero
s
TI
Inspiratory time (set on the ventilator) is shorter

than the time required for the lung to expand fully.
clipping of inspiratory flow occurs

How can we Optimize Ti ?
Flow
Inspiratory
Flow Le
Te Time
0
Li
Ti
Expiratory
Flow Note: Ti = Li
Te = Le
Li = Time lung takes to inflate. Le = Time lung takes to deflate.
Ti = Inspiratory time set on ventilator. Te = Expiratory time set on ventilator.

Ti can be set to equal Li. Te can be set to equal Le.
How can we Detect Compromise of Expiratory Flow and
Inadvertent PEEP?
Flow
Inspiratory
Flow
Time
0
Le
Te
Expiratory
Flow
Lung deflation not
completed within
the set Te
Le = Time lung takes to deflate. Te < Le

Te is too short.
Te = Expiratory time set on ventilator.
Increase Te to allow time for lung
deflation to complete.
Flow Curve during insufficient Expiration Time
L/min Flow
TE
Expiration flow does

not return to zero
Clipping of expiratory flow occurs when TE is too short relative to the time the lung needs
to empty, and this results in incomplete emptying before the next breath is delivered by
the ventilator.
• The latter is termed inadvertent PEEP, (also known as occult, intrinsic, and
auto- PEEP).
Flow Curve due to change in Resistance
change in resistance (R) to expiration is indicated by a change in expiratory flow scaling:
• increase in expiratory resistance prolonged expiratory flow scale

• decrease in expiratory resistance reduced expiratory flow scale

Effect of Setting Flow Rates on Pressure Waveform
Active Expiration
active expiration
ET-Tube Leakage via Inspection of Volume Curve
ET-Tube Leakage via Inspection of Volume Curve
ET-Tube Leakage via Inspection of Flow Curve
Leakflow
What is the "Normal" VT ?
V T in c r e a s e s
P IP P IP
PEEP PEEP
R e s is ta n c e R e s is ta n c e
C o m p lia n c e VT C o m p lia n c e
T i to o s h o rt
T e to o s h o rt
V T re d u c e s
Tidal Volume oriented Ventilator Management
 Set Tidalvolume to 5-6 ml/kg
 Set Ti, so that

longer Ti does not increase Vt,
shorter Ti does not decrease Vt
 Set Frequency to maintain desired PaCO2
 Set PEEP to adjust oxygenation
 If oxygenation continuous to be a problem

try longer Ti
try reversed I:E ratio
PV-Loop of Mechanical Stroke
mL Expiration PV-Loop
Inspiration
mbar
• PV- Loops from mechanical breath strokes move in a

counter clockwise direction
PV - Loop during CPAP without PSV
mL PV-Loop
Expiration
Inspiration
mbar
• PV - Loops during spontaneous breathing without pressure

support move in a clockwise direction.
PV-Loop during Pressure Support Ventilation
mL PV-Loop
mbar
• According to each breath of the patient during PSV,

a different airway volume is reached.
PV-Loop during CPAP with PSV
mL PV-Loop
Expiration
Inspiration
mbar
• PV-Loops in spontaneous breathing with pressure support

result in a small twist in the loop just above zero.
• The area within this loop represents trigger work of breathing

• The large right hand loop represents work of the ventilator to

deliver a breath.
P-V Loop during PSV using BabyView-Graphics
PV-Loop due to changes in Compliance
Change in compliance results in a transformation of the inspiration loop of the

PV-Loop during controlled breathing.
• increase in compliance slope of inspiratory limb increases

• decrease in compliance slope of inspiratory limb decreases

PV- Loop due to Lung-Overdistention
mL PV-Loop
stretch is
beginning
mbar
• Should the upward increment of the inspiration loop become

flatter, this may indicate overdistention of the lung.
Note: In the presence of a longer pressure plateau, an overdistention can not be
detected by PV-Loop inspection!

Visible Lung Overdistention using BabyView-Graphics
Blood Gases Normal Range
 pH 7.30 - 7.40
 pCO2 4.0 - 5.5 kPa
 pO2 5.5 - 8.0 kPa

Respiratory acidosis in a baby with RDS
Example 1
Arterial Blood Gases Settings Volumes

Case history:
Baby T. 28 weeks gestation,
pH pCO2 pO2 bic PIP/ MAP rate Ti Te O2 Vt MV
birth weight 0.80kg. Ventilated from
PEEP
birth for hyaline membrane disease,
now 48hrs of age.
7.19 8.1 8.7 19 26/5 13 66 .45 .45 66 2.1 .14
Ventilator Settings
Ti : 0.45s
Te : 0.45s
f : 66/min
Peak : 26 mbar
Peep : 5 mbar
Respiratory acidosis in a baby with RDS
Example1
Settings Volumes
Aim
•keep PO2 as it is
PIP/PEEP MAP rate Ti Te O2 Vt MV
•reduce PCO2 by
increasing MV 28/3 13 75 .4 .4 66 3.5 0.63
1.Step Improve VT
aim : 5mL/kg
Pip  28 mbar
PEEP  3 mbar
2.Step Increase MV by increasing the rate

Ti = 0.4
Te = 0.4
Blood gases after 1 hour
Example 1
Arterial Blood Gases
pH pCO2 pO2 bic
7.32 5.6 8.6 20

Respiratory alkalosis in a baby with
BPD following a PDA ligation
Example 2
Case history:
prior surgery
Baby D. Born at 26 weeks gestation,
birth weight 0.650kg. Ventilated from birth
for RDS, now 29 days old (0.7kg) with BPD. Arterial Blood Gases Settings Volumes
Still ventilator-dependent, despite two
courses of steroids. Planned surgical pH pCO2 pO2 bic PIP/ MAP rate Ti Te O2 Vt MV
ligation of patent ductus arteriosus. PEEP
7.40 4.7 8.8 22 22/3 7.8 35 .5 1.2 35 4.3 .15
Ventilator Settings
Ti : 0.5s
Te : 0.65s
f : 30/min
Peak : 27 mbar
Mean : 9 mbar
Peep : 4 mbar
Example 2
after surgery
Arterial Blood Gases Settings Volumes
pH pCO2 pO2 bic PIP/ MAP rate Ti Te O2 Vt MV

PEEP
7.58 2.2 10 16 27/4 9.0 30 .5 0.65 50 6.7 .20

Example 2
pH pCO2 pO2 bic

Aim
•reduce PO2 7.32 5.6 8.6 20
•allow pCO2 to rise
arterial blood gases

1.Step reduce VT 25 minutes later
aim : 5-6 mL/kg
2.Step reduce rate
Settings Volumes
PIP/PEEP MAP rate Ti Te O2 Vt MV

20/3 6.5 25 .5 1.9 50 4.1 0.11

Normal arterial blood gases but excessive tidal volume in a
preterm baby
Example 3
Case history: Arterial Blood Gases Settings Volumes
Baby K, born at 26 weeks gestation
weighing 700g. Maternal steroids given pH pCO2 pO2 bic PIP/ MAP rate Ti Te O2 Vt MV
during 48hrs prior to delivery. Poor Apgar PEEP
scores at birth, intubated immediately
and ventilated. Now 10 hrs old with good 7.35 5.0 8.0 20 22/3 6.0 23 .5 2.1 35 7.9 .18
oxygen saturation and CXR looks
almost clear.
Ventilator Settings
Ti : 0.5s
Te : 2.10s
f : 23/min
Peak : 22 mbar
Peep : 3 mbar
FiO2 : 35%
Normal arterial blood gases but excessive tidal volume in a
preterm baby
Example 3
Settings Volumes
Aim
Aim
•reduce
•reduceVt
Vt PIP/PEEP MAP rate Ti Te O2 Vt MV
•maintain
•maintainMV
MVand
and
normal gas
normal gas 15/3 5.7 40 .5 1.0 40 4.5
0.18
1.Step
1.Step reduce
reduceVT
VT
2.Step compensate Arterial
Arterialbloodgas
bloodgas
2.Step compensate
for
forMV
MV 11hour later
hour later
pH pCO2 pO2 bic

7.39 4.7 8.2 21

Suggested Guidelines
Normal gases may not

mean optimal ventilation!

Understanding Ventilator Curves - Drager

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Graphics in Neonatal

1. Diagnostics and Quantification

3. Optimizing Ventilator Settings

The driving force for all modes of ventilation commonly

Basic monitoring on neonatal ventilators should include

 Mean airway pressure

 Positive end expiratory pressure

The Pressure Wave

Quasi Static Dynamics of pressure

 an extra tube to manage

Pinsp PEEP/CPAP Insp. Flow

Standard controls used to Can be used to attain:

Effect on delivered breath Clinical Effect

Slower increase in airway pressure  flow into patient is more like a

 Lower MAP thus potential  Pa02

 Theorectically less barotrauma

Effect on delivered breath Clinical Effect

 May help open up atelectatic alveoli and

 May impede venous return

 Higher MAP thus potential Pa02

 PIP reached early in the

 High initial flow rate into

As a result of change in compliance, the pressure rise time of the

• increase in compliance decrease in pressure rise time

 Controls Functional Residual

Increase flow rate if Decrease flow rate if

 Pressure rise time is too quick

 Pressure rise time is too slow  A pressure plateau occurs but

 A plateau is desired but pressure

 flow is insufficient to meet

 Pressure waves do provide a lot of information about patient and ventilator

 Detailed feedback on the patients pulmonary status requires assessment of

Very low flow

 Pressure 1023 mbar

Set Inspiration Time Set Expiration Time

Peak Expiratory Flow

Li = Time lung takes to inflate. Le = Time lung takes to deflate.

Ti = Inspiratory time set on ventilator. Te = Expiratory time set on ventilator.

To avoid gas trapping Te should be

Li = Time lung takes to inflate. Ti < Li

Te = Expiratory time set on ventilator.

Inspiratory time (set on the ventilator) is shorter

clipping of inspiratory flow occurs

Li = Time lung takes to inflate. Le = Time lung takes to deflate.

Ti = Inspiratory time set on ventilator. Te = Expiratory time set on ventilator.

Le = Time lung takes to deflate. Te < Le

Expiration flow does

change in resistance (R) to expiration is indicated by a change in expiratory flow scaling:

• increase in expiratory resistance prolonged expiratory flow scale

• decrease in expiratory resistance reduced expiratory flow scale

 Set Tidalvolume to 5-6 ml/kg

 Set Ti, so that

 Set Frequency to maintain desired PaCO2

 Set PEEP to adjust oxygenation

 If oxygenation continuous to be a problem

• PV- Loops from mechanical breath strokes move in a

• PV - Loops during spontaneous breathing without pressure

• According to each breath of the patient during PSV,

• PV-Loops in spontaneous breathing with pressure support

• The area within this loop represents trigger work of breathing

• The large right hand loop represents work of the ventilator to

Change in compliance results in a transformation of the inspiration loop of the

• increase in compliance slope of inspiratory limb increases