VENTILATOR WAVEFORM

ANALYSIS ANALYSIS
By
Dr M V Nagarjuna
1
Dr. M. V. Nagarjuna
Seminar Overview
1. Basic Terminology ( Types of
variables, Breaths, modes of , ,
ventilation)
2. Ideal ventilator waveforms (Scalars) ( )
3. Diagnosing altered physiological
states
4. Ventilator Patient Asynchrony and its
management.
5. Loops (Pressure volume and Flow
volume)
2
Basics phase variables Basics phase variables..
A. Trigger .
What causes the breath to begin?
B C
B. Limit
What regulates gas flow during the breath?
C Cycle
A
C. Cycle .
What causes the breath to end?
VARIABLES VARIABLES
1 TRIGGER VARIABLE : Initiates the breath 1. TRIGGER VARIABLE : Initiates the breath
Flow (Assist breath)
Pressure (Assist Breath) Pressure (Assist Breath)
Time (Control Breath)
Newer variables (Volume Shape signal neural) Newer variables (Volume, Shape signal, neural)
Flow trigger better than Pressure trigger. ow t gge ette t a essue t gge.
With the newer ventilators, difference in work of triggering is of
minimal clinical significance. g
British Journal of Anaesthesia, 2003
4
2. TARGET VARIABLE : Controls the gas delivery during
the breath
Flow ( Volume Control modes)
Pressure ( Pressure Control modes)
3. CYCLE VARIABLE : Cycled from inspiration into
i i expiration
Volume ( Volume control)
Ti (P l) Time (Pressure control)
Flow (pressure Support)
P (Sf t li i bl ) Pressure (Safety cycling variable)
5
Modes of Ventilation
Mode of ventilation Breath types available
Volume Assist Control Volume Control, Volume Assist
Pressure Assist Control Pressure Control, Pressure Assist ,
Volume SIMV Volume Control, Volume Assist, Pressure Support
Pressure SIMV Pressure Control, Pressure Assist, Pressure Support
Pressure Support Pressure support
6
SCALARS
7
FLOW vs TIME
8
Flow versus time
Never forget to look at the expiratory limb of the flow waveform
The expiratory flow is determined by the elastic recoil of the
respiratory system and resistanceof intubated airways respiratory system and resistanceof intubated airways
9
Types of Inspiratory flow waveforms
a Square wave flow a. Square wave flow
b. Ascending ramp flow
c Descending ramp flow c. Descending ramp flow
d. Sinusoidal flow
e Decay flow e. Decay flow
10
Which form to use??
P t l d Al D l ti d fl Pressure control mode : Always Decelerating or decay flow.
Cannot be changed.
Volume control mode : Flow waveform can be changed
d di h il i depending on the ventilator options.
11
SQUARE FLOW WAVEFORM :
Inspiratory time is shortest for Inspiratory time is shortest for
Square wave flow form.
Highest Peak Inspiratory pressures
Low Mean Inspiratory pressure Low Mean Inspiratory pressure,,
thus better venous return and cardiac
output
DESCENDING RAMP FLOW :
Increases inspiratory time (if not
fixed) or peak inspiratory flow rate (if
inspiratory time is fixed) p y
Least Peak inspiratory pressures
(19% decrease).
High mean airway pressure, helps g y p , p
lung inflation and oxygenation.
12
Sinusoidal and ascending ramp flow : Sinusoidal and ascending ramp flow :
Initial flow rates are slow and hence cause dyssynchrony
FLOW STARVATION FLOW STARVATION.
Should not be used in assist modes.
Descending ramp and Square wave flow :
Usually preferred as the initial flow rate meets the flow
demand of the patient. Decreases air hunger.
13
SQUARE WAVE FLOW
DECSENDING RAMP
14
SQUARE WAVE FLOW
FLOW
Decelerating flow waveform
Advantages :
Decreases Peak inspiratory pressures
Increases oxygenation, decreases A-aDo2
Improves patient ventilator synchrony (more physiological)
Disadvantages :
Decreases expiratory time , potential for auto PEEP
Increases mean airway pressure, decreases cardiac output
Increased intracranial pressures
Egan'sFundamentalsof Respiratory Care. 8th ed. 2003:1064.
Mechanical Ventilation; Physiological and Clinical Applications4thed2006:113 Mechanical Ventilation; Physiological and Clinical Applications.4thed.2006:113.
IntensiveCareMed. 1985;11:68-75.
15
Expiratory flow waveform
Passive and determined by compliance of the lung and
resistance of the airways resistance of the airways.
F i b b d Four points to be observed :
1. Peak Expiratory Flow
2 Sl f h i li b 2. Slope of the expiratory limb
3. Expiratory time
4 D th f h th b li ? 4. Does the waveform reach the baseline?
16
PRESSURE vs TIME
17
Pressure vs Time Scalar
18
PIP
No active breathing
T t l i l it
PIP
resistance
Treats lung as single unit
Pplat
flow
Pplat
end-inspiratory
alveolar pressure
Driving

compliance
tidal volume
Pressure
(PIP-PEEP)
tidal volume
PEEP
PIP- PEEP= (Flow x Resistance) + (Vt/ Compliance RS)
tidal volume
Respiratory System Compliance
C =
Pplat - PEEP
tidal volume
Pulmonary Disorder:
Extra Pulmonary Disorder:
Decreased with:
y
mainstem intubation
congestive heart failure
ARDS
Extra Pulmonary Disorder:
abdominal distension
chest wall edema/ Obesity
ARDS
Atelectasis, consolidation
fibrosis
chest wall edema/ Obesity
thoracic deformity
Hyperinflation
Tension pneumothorax
l l ff
Normal : 100 mL/ cmH
2
O
pleural effusion
P l t PEEP = Vt/ C li Pplat PEEP = Vt/ Compliance
P plateau increased by
a) Decreasing compliance of lung : Pulm edema, ARDS, g p g
Atelectasis, Pneumonia.
b) Decreasing compliance of the chest wall : Morbid obesity,
ascites, stiff chest wall.
c) Increasing Tidal volume
d) Patient ventilator dyssynchrony
21
PIP Pplat
Inspiratory Resistance
R
i
=
PIP - Pplat
flow
Increased with:
Airways : Secretions, Mucus plugging,
Bronchospasm p
ET tube : Small size, ET block
Ventilator Circuit: Kinking Clogged HME Ventilator Circuit: Kinking, Clogged HME
Normal: 5 - 10 cm H
2
O/L/s for intubated ventilated adults
2
/ /
measured with 60 L/ min (1 L/ s) constant flow
P k P l t = Fl R i t P peak P plat = Flow x Resistance
Increased by
a) Increasing resistance : Bronchospasm, Mucus g p
plugging/ secretions, ET block , Biting the ET tube, Tube
kinking, Clogged HME.
b) Increasing flow : Increasing Vt, Increasing Insp.pause,
Increasing I:E ratio
23
PIP
Crs =
P l t PEEP
tidal volume
Ppl
Pplat - PEEP
C
tidal volume
Ppl
(Peso)
Ccw =
Peso
Palv
(Pplat)
CL =
(Pplat PEEP) - Peso
tidal volume
(Pplat)
( p )
R
i
=
PIP - Pplat
R
i
flow
STRESS INDEX (ARDS)
Increase PEEP Ideal PEEP Decrease PEEP
(Recruitment) (Overdistension)
25
SQUARE WAVE FLOW
DECSENDING RAMP
26
SQUARE WAVE FLOW
FLOW
VOLUME vs TIME
27
Information derived from VolumeTime Scalar Information derived from VolumeTime Scalar
Tidal Volume Volume on y axis
Air leak Expiratory limb failsto return to x axis
Active Expiration Tracing continues beyond the baseline
A l b f l h h b l Auto PEEP Expiratory limb fails to reach the baseline
28
HOW TO USE THE HOW TO USE THE
GRAPHS FOR GRAPHS FOR
DIAGNOSIS OF DISEASE DIAGNOSIS OF DISEASE
STATES ? STATES ?
29
Which waveforms to monitor ?
Mode of
ventilation
Independent
variables
Dependent
variables
Waveforms that will be
useful
Waveforms that
normally remain
unchanged
Volume
Control/
Assist-Control
Tidal volume,RR,
Flow rate, PEEP,
I/ E ratio
P
aw
Pressure-time:
Changes in P
ip
, P
plat
Flow-time (expiratory):
Ch i li
Volume-time
Flow time (inspiratory)
Changes in compliance
Pressure-volume loop:
Overdistension, optimal PEEP
l i d fl Pressure
Control
P
aw
, Inspiratory
time (RR), PEEP
andI/ E ratio
V
t, flow
Volume-time and flow-
time: Changes in V
t
and
compliance
Pressure-volume loop:
Pressure-time
Overdistension, optimal PEEP
Pressure PS andPEEP
V
t
and RR,
Volume- time
support/
CPAP
V
t,
and RR,
flow, I/ E
Ratio
Flow- time
(for V
t
and V
E
)
30
Increased airway resistance
(ACMV- VC)
Pressure Time Waveform :
Increased difference between Ppeak and Pplat
Normal P plat
Expiratory flow waveform :
d Decreased PEFR
Increased expiratory time
Scooped out appearance of expiratory limb Scooped out appearance of expiratory limb
Potential for auto PEEP
Loss of peak (emphysema)
Volume Time Waveform :
Expiratory limb long
31
A patient with Endotracheal Tube block (When received from Dialysis room)
32
A patient with acute severe asthma on ventilator
33
Decreased Compliance of Respiratory
System
Pressure Time Waveform :
Increased P plat and Ppeak Increased P plat and Ppeak.
Normal P peak Pplat
Flow Time Waveform :
Increased PEFR Increased PEFR
Shortened expiratory time
34
Auto PEEP/ Intrinsic PEEP Auto PEEP/ Intrinsic PEEP
Notice how the expiratory flow fails Notice how the expiratory flow fails
to return to the baseline indicating
air trapping(Auto PEEP)
Also notice how air trapping causes
an increase in airway pressure yp
due to increasing end expiratory
pressure and end inspiratory
lung volume.
35
A patient of acute severe asthma. Note failure of expiratory limb to return to baseline
36
37
AUTO- PEEP : Consequences q
Increases the work of Triggering
Ineffective triggering
Worsens Oxygenation yg
Lung Hyperinflation- barotrauma
Hemodynamic Compromise
AUTO PEEP : Recognition
Analysis of ventilator graphics:
Delay between start of Inspiratory effort and Pressure drop
No increase in P peak with increase in Applied PEEP
38
39
VENTILATOR PATIENT VENTILATOR PATIENT
SYNCHRONY SYNCHRONY
VS VS
DYS-SYNCHRONY SS C O
40
Wht i V til t P ti t S h ? What is Ventilator Patient Synchrony?
The ventilator should start inspiration at p
the time of onset of patients inspiration.
Th fl id d b th til t h ld The flow provided by the ventilator should
meet the flow demand of the patient. p
The Ventilator Inspiratory time should
t h ith th ti t i i t ti match with the patients inspiratory time.
41
Ventilator Patient Dys-synchrony
FLOW CYCLE
TRIGGER
ASYNCHRONY ASYNCHRONY
ASYNCHRONY
1. Ineffective
Triggering
2. Auto
Triggering
1. Delayed
Cycling
2 Premature
3. Double
Triggering
4. Delayed
i i
2. Premature
Cycling
triggering
42
INEFFECTIVE TRIGGGERING
One of the most common asynchronies One of the most common asynchronies
Failure of the patients inspiratory effort to initiate a
ventilator breath ventilator breath.
Identified by
Vi l i ti f ti t di th i l b t Visual inspection of patients expanding thoracic volume but
without delivery of ventilator breath.
Ventilator graphics which show a decrease in airway pressure Ventilator graphics which show a decrease in airway pressure
with an increase in flow but no initiation of breath.
43
Ineffective triggering
What causes this? What causes this?
Improper sensitivity of trigger threshold
Respiratory muscle weakness (disease related critical illness Respiratory muscle weakness (disease related, critical illness
neuromyopathy, electrolyte imbalances)
Intrinsic PEEP in COPD patients p
Decreased respiratory drive ( Excessive sedatives)
Alkaline pH p
External nebulizers
High Tidal volumes/ High Pressure support decrease respiratory g g pp p y
drive.
44
AUTO TRIGGERING
Definition : Ventilator delivers an assisted breath Definition : Ventilator delivers an assisted breath
that was not initiated by the patient
Causes :
1 Ci i l k (ET ff ICTD i h BPF ) 1. Circuit leaks (ET cuff, ICTD with BPF etc)
2. Fluid in the circuit
3. Cardiac oscillations (High cardiac output states)
4. Very low trigger threshold
.
45
DOUBLE TRIGGERING
Patients inspiration continues after the ventilator inspiration Patients inspiration continues after the ventilator inspiration
and triggers another breath immediately after the inspiration.
Also called Breath Stacking Also called Breath Stacking
Causes :
1 Hi h V il d d f h i (ARDS) 1. High Ventilatory demand of the patient (ARDS)
2. Inappropriate settings ( Low tidal volume, Short
i i i Hi h l h h ld) inspiratory time, High cycle threshold)
46
A case of Morbid Obesity with Obesity hypoventilation syndrome. y y yp y
Note the low tidal volumes generated on PSV mode
47
DELAYED TRIGGERING
Components of Triggering : Components of Triggering :
Trigger threshold : The pressure/ flow that must be
attained b the patients breath to trigger the entilator attained by the patients breath to trigger the ventilator.
Inspiratory Trigger Time (ITT) : Time from the initiation
f ff h T h h ld of effort to the Trigger threshold .
Rise Time to Baseline Pressure (RTBP)
Inspiratory Delay Time (IDT) = ITT + RTBP p y y ( )
48
DELAYED TRIGGERING
A I h t bl ith ll th ti l d f An Inherent problem with all the conventional modes of
ventilation
Can be overcome by
Newer modes of ventilation ( NAVA)
Newer methods of triggering ( Shape signal triggering)
49
Neurally Adjusted Ventilatory Assist
(NAVA)
Diaphragmatic Electrical activity is sensed by an electrode placed in the esophagus and is
used to trigger the breath and cycle into expiration.
50
Sinderby Nature Med 1999;5:1433
NEJ M 2001;344 : 1986-1996
FLOW ASYNCHRONY
Causes : Causes :
High Ventilatory demand (ALI/ ARDS)
Low ventilatory settings ( Flow rate Tidal volume Pramp) Low ventilatory settings ( Flow rate, Tidal volume, Pramp)
What to do :
Treat reversible causes of air hunger (fever acidosis) Treat reversible causes of air hunger (fever, acidosis)
Increase the tidal volume ( if feasible)
Increase the flow rate ( directly or by decreasing inspiratory Increase the flow rate ( directly, or by decreasing inspiratory
time, increasing pause)
Change to pressure control mode with variable flow g p
Sedate / Paralyze the patient (last resort)
52
Patient of ARDS being ventilated using ARDS Network strategy
(Tidal volume = 6 ml/ kg, Body weight = 66 kg)
53
Tidal volume increased to 440 ml from 400 ml to improve the flow synchrony
54
Same patient during a spike of fever 39.2 C showing severe flow dyssynchrony
55
CYCLING ASYNCHRONY
Delayed Cycling : Ventilator Ti > Patient Ti
V til t ti I i ti h t ll i ti h Ventilator continues Inspiration when actually expiration has
started.
Premature Cycling : Ventilator Ti < Patient Ti
Patients inspiratory effort continue into the expiratory
phase of ventilator breath.
56
DELAYED CYCLING
Patient while weaning . Expiratory trigger sensitivity of 25 %
57
How to Manage : How to Manage :
D I i t ti Decrease Inspiratory time
Decrease Tidal volume ( SCMV mode)
Increase Expiratory Trigger Sensitivity ( PSV mode)
58
Expiratory trigger sensitivity increased to 60 % to improve cycling synchrony.
59
A case of Acute severe asthma on SCMV mode.
I : E ratio kept at 1: 3.3 to avoid auto PEEP.
Ventilator shows double triggering
60
I : E ratio decreased to 1 : 2.5 along with control of bronchospasm.
None of the other parameters changed. No further double triggering.
Illustrates double triggering due to short inspiratory time and premature cycling
61
PATIENT VENTILATOR DYS-SYNCHRONY
CLINICAL SIGNIFICANCE ??
Increases Work Of Breathing Increases Work Of Breathing
Causes Ultra structural damage to the respiratory muscles.
Worsens Respiratory mechanics ( Auto PEEP) Worsens Respiratory mechanics ( Auto PEEP)
Alters gas exchange ( Auto, double triggering lower CO2)
Increased need for sedation Increased need for sedation
Longer duration of mechanical ventilation
Difficulty in weaning Difficulty in weaning
Confounds lung protective ventilation ( Double breaths)
Sleep Fragmentation Sleep Fragmentation
Inability to tolerate NIV
62
Loops
Pressure-Volume Loops
Flow-Volume Loops p
Pressure-Volume Loop
V
LITERS
0.6
V
T
0.4
0.6
0.2
0.4
Paw
0 20 40 60 20 40 -60
cmH
2
O
Spontaneous Breath Spontaneous Breath
V
0.6
V
T
Clockwise
CPAP
I i ti
0.4
0.6 CPAP
Inspiration
Expiration
0.2
0.4
Pressure
0 20 40 60 20 40 -60
cmH
2
O
Controlled Breath Controlled Breath
V
Anticlockwise
LITERS
0.6
V
T
Expiration
0.4
0.6
0.2
0.4
Inspiration
Paw
0 20 40 60 20 40 -60
cmH
2
O
PEEP
P-V loop and PEEP..
Assisted Breath Assisted Breath
V
LITERS
0.6
V
T Clockwise to
Counterclockwise
Expiration
0.4
0.6
Inspiration
0.2
0.4
Assisted Breath
Inspiration
Paw
Assisted Breath
0 20 40 60 20 40 -60
cmH
2
O
PEEP
Lung Compliance Changes and
the P-V Loop. (Volume mode)
Lung Compliance Changes and
the P-V Loop. (Volume mode) p ( ) p ( )
Preset V
T
C
C C
T
Volume
PIP levels
Pressure Pressure
Constant VT. Variable Pressure
Lung Compliance Changing in P-V Loop (pressure Lung Compliance Changing in P-V Loop (pressure g p g g p
mode).
g p g g p
mode).
e
l
s
1.With surfactant
2. Emphysematous L
V
T


l
e
v
e
RDS l RDSlung
Volume
Preset PIP Pressure
Constant PIP variable VT
Overdistension Overdistension
0 6
LITERS
A = inspiratory pressure
B = upper inflection point
V
T
A
0 4
0.6
pp p
C = lower inflection point
B
0 2
0.4
B
0.2
Paw
C
0 20 40
60
-20
-40
-60
Paw
cmH
2
O
Insufficient flow
Normal
V
o
l
u
m
e
Insufficient Flow
V
Cusping
Pressure
Flow-Volume Loop Flow-Volume Loop
Inspiration Inspiration
PIFR
Volume (ml)
VT
FRC
VT
E i ti
PEFR
Expiration
Air Trapping Air Trapping Air Trapping Air Trapping
Inspiration Inspiration
PIFR
Volume (ml)
VT
Does not return Does not return
VT
Does not return Does not return
to baseline to baseline
E i ti
PEFR
Expiration
Bronchodilator Response.. F-V loop
AFTER
3
Normal
Bronchospasm
Relief
3 3
2
1
2
1
2
1 1
V
LPS
.
V
T
1
V
.
1
V
.
1
2
1
2
1
2 2
3
2
3
2
3
SUMMARY
Identify the correct waveforms to monitor
S d ti t th b did Spend more time at the bedside
Never Ignore any ventilator alarm
Monitor P peak, P plat and expiratory limb of flow volume
loop to diagnose changes in lung resistance or compliance.
Identify Dys synchrony early and correct the cause.
76