1.

SELECTING THE VENTILATOR MODE

AND INITIAL SETTINGS
2.FINAL CONSIDERATIONS IN
VENTILATOR SETTINGS…
3.VENTILATOR GRAPHICS….

• CHAIRPERSON: DR PAVANI
• ASST.CHAIRPERSON: DR SHIVANI
• MODERATOR: DR. INDIRA
• POSTGRADUATE: DR SUDHA
 GOALS

• PRIMARY GOALS OF MECHANICAL

VENTILATION ARE
---ADEQUATE OXYGENATION/VENTILATION.
--- REDUCED WORK OF BREATHING.
---SYNCHRONY OF VENILATOR AND PATIENT.
--- AND AVOIDANCE OF HIGH PEAK
PRESSURES.
 MODES OF VENTILATION: THE
BASICS
• ASSIST-CONTROL VENTILATION - VOLUME CONTROL
• ASSIST-CONTROL VENTILATION - PRESSURE CONTROL
• PRESSURE SUPPORT VENTILATION
• SYNCHRONIZED INTERMITTENT MANDATORY VENTILATION
- VOLUME CONTROL
• SYNCHRONIZED INTERMITTENT MANDATORY VENTILATION
- PRESSURE CONTROL
 BREATH SEQUENCE

• CONTINUOUS MANDATORY ALL BREATHS ARE CONTROLLED BY

THE VENTILATOR. NO SPONTANEOUS BREATHS ARE ALLOWED.
[EX: CMV]
• INTERMITTENT MANDATORY-SET NO. OF MANDATORY BREATHS
ARE PROVIDED BY THE VENTILATOR.SPONTANEOUS BREATHS ARE
ALLOWED BETWEEN MANDATORY BREATHS[EX: SIMV]
• CONTINUOUS SPONTANEOUSALL BREATHS ARE SPONTANEOUS
WITH ASSISTANCE[EX: PRESSURE SUPPORT VENTILATION OR PSV]
OR WITHOUT ASSISTANCE [EX: CONTINUOUS POSITIVE AIRWAY
PRESSURE OR CPAP]
 ASSIST CONTROL VENTILATION

• A SET TIDAL VOLUME (IF SET TO

VOLUME CONTROL) OR A SET PRESSURE
AND TIME (IF SET TO PRESSURE
CONTROL) IS DELIVERED AT A MINIMUM
RATE
• ADDITIONAL VENTILATOR BREATHS ARE
GIVEN IF TRIGGERED BY THE PATIENT
 INITIAL SETTINGS DURING
VOLUME VENTILATION
SETTINGS:
PRIMARY GOAL OF
• MINUTE VENTILATION (RATE AND
VOLUME VENTILATION IS
TIDAL VOLUME)
TO ACHIEVE A DESIRED
• INSPIRATORY GAS FLOW
MINUTE VENTILATION
• FLOW WAVEFORM
THAT MATCHES THE
• INSPIRATORY TO EXPIRATORY (I:E)
PATIENT'S METABOLIC RATIO
NEEDS AND • PRESSURE LIMIT
ACCOMPLISHES ADEQUATE • INFLATION HOLD
GAS EXCHANGE. • PEEP
 TIDAL VOLUME AND RATE

• NORMAL SPONTANEOUS TIDAL VOLUME

5-7 ML/KG
- VENTILATED PATIENTS 6-12 ML/KG IBW FOR ADULTS AND 5-10
ML/KG IBW FOR CHILDREN AND INFANTS

• NORMAL SPONTANEOUS RATE

12-18 BREATHS/MINUTE

• NORMAL SPONTANEOUS MINUTE VENTILATION

100ML/KGIBW
 WHEN SETTING THE RATE AND TIDAL VOLUME THE
GOAL IS NOT TO FOCUS SO MUCH ON THE EXACT TIDAL
VOLUME AND RATE, BUT TO FOCUS ON SETTING THEM
IN A WAY THAT DOES NO HARM TO THE PATIENT

• NORMAL LUNGS:
• VT OF10-12 ML/KG IBW
• RATE 8-12/MIN
• RESTRICTIVE LUNGS:
• VT OF 4-8ML/KG IBW
• RATE 15-25 (WATCH I:E RATIO FOR ENOUGH
EXHALATION TIME)
• AIRWAYS OBSTRUCTION AND RESISTANCE:
• VT OF 8-10 ML/KG IBW
• RATE 8-12/MIN
 MINUTE VENTILATION
• MINUTE VENTILATION IS THE AMOUNT OF AIR INSPIRED OR
EXPIRED IN ONE MINUTE.
• MV = [TIDAL VOL MINUS DEADSPACE VOL] * RESPIRATORY RATE.
• 5 TO 6 LITRES/MIN IN HEALTHY INDIVIDUALS AT REST
• INCREASES AMONG PATIENTS WHO ARE MECHANICALLY
VENTILATED OR HAVE INCREASED CARBONDIOXIDE
PRODUCTION
• -FEVER
• -HYPERMETABOLIC STATES
• -HYPOXEMIA
• INCREASED DEAD SPACE
• INCREASED CENTRAL RESPIRATORY DRIVE.
 RATE OF GAS FLOW
THE FLOW SETTING ESTIMATES THE
DELIVERED FLOW OF INSPIRED GASES.
INITIAL PEAK FLOW SETTING IS
60ML/MIN[40-80]

HIGH FLOW LOW FLOW

• SHORT TI • PROLONGED TI
• HIGH PIP • LOW PIP
• POOR GAS DISTRIBUTION • IMPROVED GAS
DISTRIBUTION
• INCREASED P{AW}AIR
TRAPPING
 TUBING COMPLIANCE
• REFLECTS THE AMOUNT OF GAS (ML)
COMPRESSED IN THE VENTILATOR CIRCUIT
FOR EVERY CMH2O OF PRESSURE
GENERATED BY THE VENTILATOR DURING
THE INSPIRATORY PHASE
• CT = ΔV/ΔP ML/CMH2O
• THE TOTAL VOLUME THAT GOES TO THE
CIRCUIT NEVER REACHES THE PATIENT
• THE COMPRESSIBLE VOLUME IS THE
VOLUME OF GAS IN THE CIRCUIT AND VARIES
DEPENDING ON THE TYPE OF CIRCUIT
 MECHANICAL DEAD SPACE

• THE VOLUME OF GAS THAT IS RE-BREATHED DURING

VENTILATION.
• ANYTHING ADDED TO THE VENTILATOR CIRCUIT BETWEEN
THE Y-CONNECTOR AND THE PATIENT
-CORRUGATED TUBING
-HME’S [HEAT MOISTURE EXCHANGER]
-INLINE SUCTION CATHETERS
 INSPIRATORY FLOW PATTERNS
SELECTION DEPENDS ON LUNG CONDITION
• CONSTANT FLOW –
SQUARE WAVEFORM
• PROVIDES THE SHORTENED
TI
• ASCENDING RAMP
• NOT GENERALLY USED
• SINE FLOW
• TAPERED FLOW MAY MORE
EVENLY DISTRIBUTE GAS TO
LUNGS
• DESCENDING RAMP
• ATTEMPTS TO MEET
PATIENTS FLOW DEMAND,
FLOW IS GREATEST AT THE
BEGINNING OF INSPIRATION
 COMPARISION OF CONSTANT AND
DESCENDING RAMP FLOW

CONSTANT FLOW DESCENDING RAMP

• SHORTEST TI • LOWER PIP

• RAISES PIP • HIGHER PAW

• IMPROVES GAS DITRIBUTION
• REDUCES DEAD SPACE
VENTILATION
• INCREASES OXYGENATION
BY INCREASING MEAN AND
PLATEAU PRESSURES.
 INTERRELATION OF VT, FLOW,
INS TIME, EXP TIME, TCT, AND
RR
.TCT [TOTAL CYCLE TIME]= TI [INSPIRATORY TIME]
+TE[EXPIRATORY TIME]
• RR (F) = 1 MIN/TCT OR 60SEC/TCT
TCT = 60SEC/F

• I:E = TI/TE
• TI=VT/FLOW
 INSPIRATORY TIME: EXPIRATORY
TIME RELATIONSHIP (I:E RATIO)
• DURING SPONTANEOUS BREATHING,
-- THE NORMAL I:E RATIO IS 1:2- INDICATING THAT
FOR NORMAL PATIENTS THE EXHALATION TIME IS
ABOUT TWICE AS LONG AS INHALATION TIME.
• IF EXHALATION TIME IS TOO SHORT--- “BREATH
STACKING” OCCURS RESULTING IN AN INCREASE IN
END-EXPIRATORY PRESSURE ALSO CALLED AUTO-
PEEP.
• DEPENDING ON THE DISEASE PROCESS, -SUCH AS IN
ARDS, THE I:E RATIO CAN BE CHANGED TO IMPROVE
VENTILATION
 INSPIRATORY PAUSE
• A MANEUVER THAT PREVENTS THE
EXPIRATORY VALVE FROM OPENING FOR A
SHORT TIME AT THE END OF
INSPIRATION,WHEN THE INSPIRATORY VALVE
IS ALSO CLOSED.
• MOST FREQUENTLY USED TO OBTAIN AN
ESTIMATE OF THE PLATEAU PRESSURE
• IT IS USED TO IMPROVE
- DISTRIBUTION OF AIR IN THE LUNGS,
-PROVIDE OPTIMUM V/Q MATCHING AND
- REDUCE VD/VT RATIOS.
• IT INCREASES PAW AND REDUCES
PULMONARY BLOOD FLOW..
 INITIAL SETTINGS DURING
PRESSURE VENTILATION
• PRESSURE VENTILATION SETTINGS
HAS THE ADVANTAGE OF
LIMITING PRESSURES TO • BASELINE PRESSURE (PEEP)
AVOID OVER-INFLATION • IP IS SET AT A LOW
AND PROVIDING FLOW
PRESSURE (10-15CMH20)
ON DEMAND
AND ADJUSTED TO ATTAIN
• THE CHANGE IN THE DESIRED VOLUME
PRESSURE BETWEEN THE
BASELINE AND PIP IS SET • RATE, TI, AND I:E ARE SET
TO ESTABLISH THE VT JUST AS IN VOLUME
DELIVERY (PEEP VENTILATION
COMPENSATION)
 POSITIVE END-EXPIRATORY
PRESSURE (PEEP)
• PEEP IS ADDED TO MITIGATE END-EXPIRATORY ALVEOLAR
COLLAPSE
• . NORMALLY APPLIED PEEP IS 5 CMH2O.
• HOWEVER, UP TO 20 CMH2O MAY BE USED IN PATIENTS
UNDERGOING LOW TIDAL VOLUME VENTILATION FOR ACUTE
RESPIRATORY DISTRESS SYNDROME (ARDS)
• AUTO-PEEP:
• INCOMPLETE EXPIRATION PRIOR TO THE INITIATION OF NEXT
BREATH CAUSES PROGRESSIVE AIR
TRAPPING(HYPERINFLATION). THIS ACCUMULATION OF AIR
INCREASES ALVEOLAR PRESSURE AT END OF
EXPIRATION,WHICH IS REFERRED TO AS AUTO-PEEP..
 PRESSURE SUPPORT
VENTILATION
THE VENTILATOR PROVIDES A
CONSTANT PRESSURE DURING
INSPIRATION ONCE IT SENSES
THE PATIENT HAS MADE AN
INSPIRATORY EFFORT
PSV GOALS
1.TO HELP INCREASE THE VT (4-8ML/KG)
2.TO DECREASE THE RESIRATORY RATE (<30 BREATHS/MIN)
3.TO DECREASE THE WORK OF BREATHING .
 INITIAL SETTINGS DURING
PRESSURE SUPPORT
VENTILATION
• PSV IS USED BEFORE THE • FOR PATIENTS WITHOUT
PROCESS OF WEANING LUNG DISEASE, ABOUT 5CM
H2O IS USED TO
• THE PRESSURE IS SET AT A
COMPENSATE FOR
LEVEL TO PREVENT A
ADDITIONAL WORK OF
FATIGUING WORKLOAD ON BREATHING.
THE RESPIRATORY MUSCLES
• FOR PATIENTS WITH LUNG
• LEVEL OF PS CAN BE SET DISEASE ,8-14 CM OF H2O
BASED ON AIRWAY ARE USED TO COMPENSATE
RESISTANCE OR EQUAL TO FOR ADDITIONAL WORK OF
PTA[PIP-PPLAT] BREATHING.
 SYNCHRONIZED INTERMITTENT
MANDATORY VENTILATION
 BREATHS ARE GIVEN AT A SET MINIMAL RATE, HOWEVER IF
THE PATIENT CHOOSES TO BREATH OVER THE SET RATE NO
ADDITIONAL SUPPORT IS GIVEN
 ONE ADVANTAGE OF SIMV IS THAT IT ALLOWS PATIENTS TO
ASSUME A PORTION OF THEIR VENTILATORY DRIVE
 SIMV IS USUALLY ASSOCIATED WITH GREATER WORK OF
BREATHING THAN AC VENTILATION AND THEREFORE IS LESS
FREQUENTLY USED AS THE INITIAL VENTILATOR MODE
 LIKE AC, SIMV CAN DELIVER SET TIDAL VOLUMES (VOLUME
CONTROL) OR A SET PRESSURE AND TIME (PRESSURE CONTROL)
 NEGATIVE INSPIRATORY PRESSURE GENERATED BY
SPONTANEOUS BREATHING LEADS TO INCREASED VENOUS
RETURN, WHICH HELP CARDIAC OUTPUT AND FUNCTION .
 FRACTION OF INSPIRED OXYGEN
• FIO2 IS DEFINED AS THE PERCENTAGE OR CONCENTRATION OF
OXYGEN THAT IS DELIVERED.
• THE LOWEST POSSIBLE FIO2 SHOULD BE USED TO MEET
OXYGENATION GOALS .
• THIS WILL DECREASE THE ADVERSE CONSEQUENCES OF
SUPPLEMENTAL OXYGEN TO DEVELOP -SUCH AS
-- ABSORPTION ATELECTASIS,
-- ACCENTUATION OF HYPERCAPNIA,
-- AIRWAY INJURY,
-- PARENCHYMAL INJURY
 ADVANTAGES OF EACH MODE
Mode Advantages

Assist Control Ventilation (AC) Reduced work of breathing compared to

spontaneous breathing

AC Volume Ventilation Guarantees delivery of set tidal volume

AC Pressure Control Ventilation Allows limitation of peak inspiratory

pressures

Pressure Support Ventilation (PSV) Patient comfort, improved patient

ventilator interaction

Synchronized Intermittent Mandatory Less interference with normal

Ventilation (SIMV) cardiovascular function
 DISADVANTAGES OF EACH MODE
Mode Disadvantages
Assist Control Ventilation (AC) Potential adverse hemodynamic effects,
may lead to inappropriate hyperventilation

AC Volume Ventilation May lead to excessive inspiratory

pressures

AC Pressure Control Ventilation Potential hyper- or hypoventilation with

lung resistance/compliance changes

Pressure Support Ventilation (PSV) Apnea alarm is only back-up, variable

patient tolerance

Synchronized Intermittent Mandatory Increased work of breathing compared to

Ventilation (SIMV) AC
FINAL CONSIDERATIONS IN VENTILATOR
EQUIPMENT SETUP
• BEFORE INITIATING MV, WE SHOULD PERFORM A FINAL CHECK
OF THE EQUIPMENT TO BE USED. THIS CHECK INCLUDES THE
FOLLOWING STEPS:
• 1.CHECK VENTILATOR AND CIRCUIT FUNCTION TO ENSURE
THEY ARE OPERATING CORRECTLY AND NO SIGNIFICANT LEAKS
ARE PRESENT.
• 2.FILL THE HUMIDIFIER WITH STERILE WATER ,AND SET THE
HUMIDIFIER TEMP SO THAT THE FINAL GAS TEMP AT THE
AIRWAY WILL BE APPROX 31 DEGREES TO 35 DEGREES C,OR
PLACE AN HME IN LINE.
• 3.PLACE A TEMP MONITORING DEVICE NEAR THE PATIENT
CONNECTOR WHEN HEATED HUMIDIFICATION IS USED.
• 4.CHECK FIO2,SET VT AND F
• 5.ADJUST THE ALARMS.
 CONT…
• 6.ENSURE THE PATIENT IS CONNECTED TO AN
ELECTROCARDIOGRAPHIC MONITOR.
• 7.HAVE AN EMERGENCY AIRWAY TRAY AVAILABLE IN CASE
THE PATIENTS AIRWAY IS REMOVED OR DAMAGED.
• 8. CHECK THAT SUCTIONING EQUIPMENT IS AVAILABLE AND
FUNCTIONING.
• 9.SELECT A VOLUME-MONITORING DEVICE AND AN
OXYGEN ANALYZER IF ONE IS NOT AVAILABLE WITH THE
VENTILATOR.
• 10. ENSURE THAT A MANUAL RESUSCITATION BAG IS
AVAILABLE AND EASILY ACCESSIBLE.
 VENTILATOR GRAPHICS
PURPOSE OF GRAPHICS
 Graphics are waveforms that reflect the patient-
ventilator system and their interaction.
 Purpose of monitoring graphics includes:
• Allows user to interpret, evaluate, and troubleshoot
the ventilator and the patient’s response to
ventilator.
• Monitors the patient’s disease status (C and Raw).
• Assesses patient’s response to therapy.
• Monitors ventilator function
• Allows fine tuning of ventilator to decrease WOB,
optimize ventilation, and maximize patient comfort.
 TYPES OF WAVEFORMS
 Scalars: plots pressure/volume/flow against
time… time is the x axis
 Loops: plots pressure/volume/flow against
each other…there is no time component
 Six basic waveforms:
• Square: rectangular or constant wave
• Ascending Ramp: accelerating ramp
• Descending Ramp: decelerating ramp
• Sinusoidal: sine wave
• Exponential rising
• Exponential decaying
• Generally, the ascending/descending ramps are considered the same as the
exponential ramps.
 TYPES OF
WAVEFORMS Pressure
VOLUME MODES
Modes

Volume Control/ SIMV (Vol. Pressure Control/ Pressure

Control) PRVC SIMV (PRVC) Support/
SIMV (Press. Control) Volume Support
PRESSURE/TIME
SCALAR

Inspiratory
pause
1
2

A = MAP
B

1 = Peak Inspiratory Pressure (PIP) 2 = Plateau

Pressure (Pplat)
A = Airway Resistance (Raw)
B = Alveolar Distending Pressure
•The area under the entire curve represents the
mean airway pressure (MAP).
 PRESSURE/TIME
SCALAR
• In Volume
 In Pressure modes, the
modes, shape will be
the shape will be rectangular or square.
an exponential  This means that
rise or an pressure
accelerating ramp remains constant
throughout the breath
for mandatory cycle.
breaths.

•In Volume modes, adding an inspiratory pause may improve distribution of

ventilation.
PRESSURE/TIME SCALAR

Can be used to assess:

•Air trapping (auto-PEEP)
•Airway Obstruction
•Bronchodilator Response
•Respiratory Mechanics (C/Raw)
•Active Exhalation
•Breath Type (Pressure vs. Volume)
•PIP, Pplat
•CPAP, PEEP
•Asynchrony
•Triggering Effort
 PRESSURE/TIME
SCALAR

1
5

5
PEEP +5

No patient Patient
effort effort

•The baseline for the pressure waveform increases when PEEP is added.
•There will be a negative deflection just before the waveform with
patient triggered breaths.
 PRESSURE/TIME
SCALAR

Increased Airway Decreased

Resistance B. Compliance
A. PI
P
PIP
Pplat
Pplat

•A-An increase in airway resistance causes the PIP to increase, but Pplat
pressure remains normal.
•B-A decrease in lung compliance causes the entire waveform to increase in
size. The difference between PIP and Pplat remain normal.
VOLUME/TIME
SCALAR

Inspiratory Tidal Volume

Exhaled volume returns to baseline

 VOLUME/TIME
SCALAR
 The Volume waveform will generally have a “mountain
peak” appearance at the top. It may also have a plateau,
or “flattened” area at the peak of the waveform.

•There will also be a plateau if an inspiratory pause set or inspiratory hold maneuver
is applied to the breath.
VOLUME/TIME SCALAR

Can be used to assess:

•Air trapping (auto-PEEP)

•Leaks

•Tidal Volume
•Active Exhalation
•Asynchrony
 VOLUME/TIME
SCALAR

Air-Trapping or
Leak

Loss of
volume

•If the exhalation side of the waveform doesn’t return to baseline, it could
be from air-trapping or there could be a leak (ETT, vent circuit, chest tube,
etc.)
FLOW/TIME
SCALAR

Volume Pressur
e
FLOW/TIME SCALAR

 In Volume modes, the  In Pressure

shape of the waveform
will be square or modes, (PC, PS,
rectangular. PRVC,
 This means that flow
remains constant VS) the shape of the
throughout the breath waveform will
cycle. have a
decelerating ramp
flow
pattern.
FLOW/TIME
SCALAR
Can be used to assess:

•Air trapping (auto-PEEP)

•Airway Obstruction
•Bronchodilator Response
•Active Exhalation
•Breath Type (Pressure vs. Volume)
•Flow Waveform Shape
•Inspiratory Flow
•Asynchrony
•Triggering Effort
 FLOW/TIME
SCALAR
Auto-Peep (air trapping)

=
Normal
Expiratory flow
doesn’t return
to baseline

Start of next
breath

•If expiratory flow doesn’t return to baseline before the next breath starts,that means
there’s AUTO- PEEP (air trapping) present , e.g. emphysema.
FLOW/TIME
SCALAR

Bronchodilator Response
Pre-Bronchodilator Post-Bronchodilator

Longer Shorte
E- r E-
time time

Peak Exp.
Flow
Improved Peak Exp. Flow

•To assess response to

bronchodilator therapy, you
should see an increase in peak
expiratory flow rate.
TYPES OF WAVEFORMS
Volume Pressure
Modes Modes

Volume Control/ SIMV (Vol. Pressure Control/ Pressure

control) PRVC SIMV (PRVC) Support/
SIMV (Press. control) Volume Support
•In Pressure Limited, Time-cycled (control) modes, inspiratory flow should return to
baseline.
PRESSURE/VOLUME
LOOPS

Dynamic
Complianc
B e
B = Exp. (Cdyn)
ion
500
t A = Inspiratory
Resistance/ a
pir A Resistance/
Elastic WOB ex Resistive WOB
tion
p ira
250 ins

5 15 30

•The top part of the P/V loop represents Dynamic compliance

(Cdyn).
•Cdyn = Δvolume/Δpressure
PRESSURE /VOLUME
LOOPS
 Volume is plotted on the y-axis, Pressure on the x-
axis.
 Inspiratory curve is upward, Expiratory curve is
downward.
 Spontaneous breaths go clockwise and positive
pressure breaths go counterclockwise.
 The bottom of the loop will be at the set PEEP
level.
It will be at 0 if there’s no PEEP set.
 If an imaginary line is drawn down the middle of
the loop, the area to the right represents
inspiratory resistance and the area to the left
represents expiratory resistance.
PRESSURE/VOLUME
LOOPS
Can be used to assess:

•Lung Overdistention
•Airway Obstruction
•Bronchodilator Response
•Respiratory Mechanics (C/Raw)
•WOB
•Flow Starvation
•Leaks
•Triggering Effort
 PRESSURE/VOLUME LOOPS

OVERDISTENTION
“beaking”

500

250

5 15 30

•Pressure continues to rise with little or no change in volume, creating a “bird

beak”.
•Fixed by reducing amount of tidal volume delivered.
 PRESSURE/VOLUME LOOPS

AIRWAY RESISTANCE

n ce
a
ist
500

e s
p .r
ex i s ”
s
re
s te
y
250 “h c e
tan
is
es
p.r
s
in
5 15 30

•As airway resistance increases, the loop will become wider.

•An increase in expiratory resistance is more commonly seen. Increased
inspiratory resistance is usually from a kinked ETT or patient biting.
PRESSURE/VOLUME
LOOPS
Increased Decreased
Compliance Compliance

500 500

250 250

15 30 15 30

Example: Example: ARDS,

Emphysema, CHF,
Surfactant Therapy Atelectasis
FLOW/VOLUME
LOOPS

60

40

20
Start of Start of
Inspiration Expiratio
0 n
200 400 600

-20

-40

-60
PE
F
FLOW/VOLUME
LOOPS

 Flow is plotted on the y axis and volume on the x axis

 Flow volume loops used for ventilator graphics are the
same as ones used for Pulmonary Function Testing,
(usually upside down).
 Inspiration is above the horizontal line and expiration is
below.
 The shape of the inspiratory curve will match what’s set
on the ventilator.
 The shape of the exp flow curve represents passive
exhalation…it’s long and more drawn out in patients with
less recoil.
 Can be used to determine the PIF, PEF, and Vt
 Looks circular with spontaneous breaths
FLOW/VOLUME LOOPS

Can be used to assess:

•Air trapping
•Airway Obstruction
•Airway Resistance
•Bronchodilator Response
•Insp/Exp Flow
•Flow Starvation
•Leaks
•Water or Secretion accumulation
•Asynchrony
 FLOW/VOLUME
LOOPS

•The shape of the inspiratory curve will match the flow setting on the
ventilator.
 FLOW /VOLUME LOOPS

Airway
Obstruction

Reduce
“scooping” d
PEF

•The F-V loop appears “upside down” on most ventilators.

•The expiratory curve “scoops” with diseases with small airway obstruction
(high expiratory resistance). e.g. asthma, emphysema.
 FLOW/ VOLUME
LOOPS
A
60
Leak
=
40 Normal

20

0
200 400 600

Expiratory -20
portion of
loop does not -40
return to
starting point,
-60
indicating a
leak.
•If there is a leak, the loop will not meet at the starting point where inhalation starts
and exhalation ends. It can also occur with air-trapping.
PRESSURE/VOLUME
LOOPS A
Leak

500

250

5 15 30

•The expiratory portion of the loop doesn’t return to baseline. This indicates a
leak.
 L EAKS


• Expiratory leak: ETT cuff leak , chest tube leak, Broncho Pleural
Causes
fistula, NG tube in trachea
•Inspiratory leak: loose connections, ventilator malfunction, faulty
flow sensor
 How to ID
it • Pressure wave: Decreased PIP
• Volume wave:Expiratory side of wave doesn’t return to
• baseline Flow wave: PEF decreased
• Pressure/Volume loop: exp side doesn’t return to the baseline
• Flow/Volume loop: exp side doesn’t return to baseline
 How to fix it
• Check possible causes listed above
• Do a leak test and make sure all connections are
tight
 AIRWAY RESISTANCE
CHANGES

• Bronchospasm
Causes:
• ETT problems (too small, kinked, obstructed, patient
• biting) High flow rate
• Secretion build-up
• Damp or blocked expiratory valve/filter Water in the HME
•
 How to Identify it on the graphics
• Pressure wave: PIP increases, but the plateau stays the same
• Flow wave: it takes longer for the exp side to reach baseline/exp flow
rate is reduced
• Volume wave: it takes longer for the exp curve to reach the baseline
• Pressure/Volume loop: the loop will be wider. Increase Insp. Resistance
will cause it to bulge to the right. Exp resistance, bulges to the left.
• Flow/Volume loop: decreased exp flow with a scoop in the exp curve
 How to fix
• Give treatment, suction patient, drain water, change HME, change ETT,
add a bite block, reduce PF rate, change exp filter.
 ASYNCHRONY
THIS OCCURS WHEN THE TIMING OF THE VENTILATOR CYCLE IS NOT
SIMULTANEOUS WITH THE TIMING OF THE PATIENTS RESPIRATORY CYCLE
Causes (Flow, Rate, or Triggering)
 Air hunger (flow
•
starvation)
• Neurological Injury
How•toImproperly
ID it set sensitivity

•
• PRESSURE WAVE: PATIENT TRIES TO INHALE/EXHALE IN THE MIDDLE OF THE
WAVEFORM, CAUSING A DIP IN THE PRESSURE
•
• FLOW WAVE: PATIENT TRIES TO INHALE/EXHALE IN THE MIDDLE OF THE
WAVEFORM, CAUSING ERRATIC FLOWS/DIPS IN THE WAVEFORM
•
• PRESSURE/VOLUME LOOP: PATIENT MAKES EFFORT TO BREATH CAUSING DIPS IN
LOOP
• EITHER INSP/EXP.
• FLOW/VOLUME LOOP: PATIENT MAKES EFFORT TO BREATH CAUSING DIPS IN
LOOP EITHER INSP/EXP.

•
•
 ASYNCHRONY

Flow
Starvation

•The inspiratory portion of the pressure wave shows a scooping or “dip”, due
to inadequate flow.
 ASYNCHRONY

F/V P/V
Loop Loop
 RISE TIME cc
•The amount of time to reach
•the desired airway pressure
•or peak flow rate.

•Used to assess if ventilator is meeting

patient’s demand in Pressure Support
mode.
In SIMV, rise time becomes a %
of the breath cycle.
 INSPIRATORY CYCLE OFF
•The inspiratory cycle off determines when the
ventilator flow cycles from inspiration to expiration,
in Pressure Support mode.

Also know as–

•Inspiratory flow termination,
•Expiratory flow sensitivity,
•Inspiratory flow cycle %,
•E-cycle etc…

•The flow-cycling variable is given different names depending on the type of

ventilator.
 INSPIRATORY CYCLE OFF

Inspiration
ends

pressur
e

flow

•The breath ends when the ventilator detects inspiratory flow has dropped to a
specific flow value.
 INSPIRATORY CYCLE OFF

100% of Patient’s
Peak Inspiratory Flow
100
%
75%
50%
30%

•In the above example, the machine is set to cycle inspiration off at 30% of the
patient’s peak inspiratory flow.
 INSPIRATORY CYCLE OFF
Exhalatio
A B
n spike

100 100
% %
60
% 10
%

•A –The cycle off percentage is too high, cycling off too soon. This makes the breath
too small. (not enough Vt.)
•B – The cycle off percentage is too low, making the breath too long. This forces the
patient to actively exhale (increase WOB), creating an exhalation “spike”.
THANK YOU…..