bilgrami, irma — reading the vent like an ecg
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Reading the Ventilator Like An ECG
OBJECTIVES SYSTEMIncorporate ventilator information in patient assessment
Course in mechanical ventilation
Advanced course in ventilator waveform analysis
Respiratory physiology
WHAT IS NORMAL- in brief
HAVE A SYSTEM- like an ECG
CASE STUDIES
What is normal???
VentilatorsAlarmsVentilator graphics
PRESSURE
FLOW
VOLUME
VENTILATOR GRAPHICS
WAVEFORMS
LOOPS
Pressure vs volumeFlow Vs Volume
Volume ModeP
CmH20
30
20
10
0
Flow L/min
80
40
0
-40
Vtmls
300
200
100
0
Time(s)
Time(s)
Time(s)
A
B
C
a
b c
d
e f
Time
Time
Time
Pressure Mode
Volume
Pressure
Flow
Inspiration Expiration
Flow wave form = Decelerating
Affected by changes in compliance/ resistance
Pressure waveform= rectangular
Not affected by change in compliance/ resistance
VOLUME mode
Descending Ramp Flow Pattern
THIS TALK
Have a System
A) Patient AssessmentReport ECG findingsDesc
ribeInterpret
Patient Assessment
B) Technical quality
C) Report Ventilator findings
A) Patient AssessmentReport ECG findingsDesc
ribeInterpret
Patient Assessment
Oxygen Saturations
End Tidal CO2 Trace
Haemodynamics
B) Technical qualityReport ECG findingsDesc
ribeInterpret
Patient Assessment
Know your ventilator
..and the alarms
C) Report Ventilator findingsReport ECG findingsDesc
ribeInterpret
Patient Assessment
1) Mode?
2) Parameters set and achieved?
4) Interpretation?
3) Information from waveforms/manoeuvres ?
3) Report Ventilator findings
VOLUME mode
Volume set, pressure variable
Pressure mode
Pressure set, volume variable
1) Mode?
2) Parameters set
3) Report Ventilator findings
VolumeRespiratory rate
Inspiratory Flow RateInspiratory Time
FIO2PEEP
2) Parameters achieved
Peak Pressure
Volume-expiratory
I:E ratio achieved
3) Information from waveforms/manoeuvres
3) Report Ventilator findings
Influenced by ComplianceResistanceFlow pattern
Values
Pattern
Curve meet baseline
VOLUME MODE
Values
Pattern
Peak pressure
? Problem with
airway resistance or lung compliance
HIGH AIRWAY PRESSURES
Inspiratory Hold ManoeuvreAssess Plateau Pressure
HIGH PLATEAU PRESSURESLow complianceGas trapping
Expiratory Hold ManoeuvreAssess Auto-PEEP
Values
PIFR
Values
Pattern
Expiratory flow reaches baseline well before expiratory time has ended
AUC
PEFR
Pattern
VOLUME MODE
Set by the userDecelerating Square
Not affected by change in lung characteristics
Values
Pattern
Tidal volume
Values
Pattern
Return to baseline
VOLUME MODE
time
4) Interpretation?
C) Report Ventilator findings
Safe ventilation?TV 6-8ml/kgPplat<30
Safe oxygenation?FiO2<60%
Other problems:Low Compliance
High Resistance
A) Patient AssessmentReport ECG findingsDesc
ribeInterpret
Patient Assessment
B) Technical qualityC) Report Ventilator findings
1) Mode?
2) Parameters set and achieved?
4) Interpretation?
3) Information from waveforms/manoeuvres ?
Safe ventilation?Safe oxygenation?Other problems
If you change the ventilator settings
REASSESS the patient
New Admissions overnightMatt: Drug overdose
Rosa: Severe pneumonia
Ms Smith: Asthma
Morning Ward Round
Matt24yr old man
Drug overdose
24year old manBenzodiazepine overdose
Currently intubated/ ventilated
Weight 70 kg (predicted body weight)
History
Examination
Examination
INFUSIONS:
Propofol 100mg/hour
PHYSICAL EXAM
ETT Size 8.5Minimal secretionsUnremarkable exam
Investigations
Ventilator
What mode
Parameters set and achievedOxygenationVentilation
Interpretation
Waveforms
MODE Parameters set
The Ventilator
Parameters achieved
Information from waveforms
The Ventilator
INTERPRETATION
IS VENTILATION SAFE?
IS OXYGENATION SAFE?
Other ISSUES?
Safe ventilation?TV 6-8ml/kgPplat<30
Safe oxygenation?FiO2<60%
Other problems:Low ComplianceHigh Resistance
I:E ratio of 1:1
A) Patient AssessmentReport ECG findingsDesc
ribeInterpret
Patient Assessment
B) Technical qualityC) Report Ventilator findings
1) Mode?
2) Parameters set and achieved?
4) Interpretation?
3) Information from waveforms/manoeuvres ?
Safe ventilation?Safe oxygenation?Other problems
Morning Ward Round
ROSA36yr Lady
Pneumonia
PROBLEM WITH LUNG COMPLIANCE?
Lung parenchymaPleuraChest wall
PRESSURE TIME CURVEVolume mode
Values
Pattern
Increased PIP
Same shape. Higher pressures
Values
Pattern
Expiratory limb back to baseline
FLOW TIME CURVEVolume mode
Values
Pattern
Increased Expiratory flow rate
Flow pattern normalArea under curve same in bothCurve finishes earlier
Values
Pattern
No Change
HISTORY
Rosa, 36 year old lady with respiratory failure 2’ to Community acquired pneumonia
Day 1 ICU
Weight= 80 Kg (Predicted body weight)
History
EXAM
INFUSIONS:
Morphine 10mg/hrMidazolam: 10mg/hrNoradrenaline : 5 mcg/min
EXAM
PHYSICAL EXAM
ETT Size 8Purulent secretionsCoarse creps , reduced air entry
Investigations
PHYSICAL EXAM
ETT Size 8Purulent secretionsCoarse creps , reduced air entry
ABG
pH 7.33PaCo2 57PaO2 65HCO3 24BE 0
Sats 85%
Ventilator
What mode
Parameters set and achievedOxygenationVentilation
Interpretation
Waveforms
MODEParameters set
The Ventilator
Parameters achieved
Information from waveforms
FT
The Ventilator
IncreasePeak pressure? Plateau pressure
IncreaseExpiratory flow rate
Inspiratory pause Expiratory pause
INTERPRETATION
Severe respiratory failure with P/F ratio of 65Poor lung compliance, with high plateau pressures
IS VENTILATION SAFE?
IS OXYGENATION SAFE?
Other ISSUES?
Safe ventilation?TV 6-8ml/kgPplat<30
Safe oxygenation?FiO2<60%
Other problems:Low ComplianceHigh Resistance
MANAGE Patient
MANAGE Ventilator
PositionSedate / ParalyseFluid balance
Lung protective ventilationOptimum PEEP
Consider rescue treatments
A) Patient AssessmentReport ECG findingsDesc
ribeInterpret
Patient Assessment
B) Technical qualityC) Report Ventilator findings
1) Mode?
2) Parameters set and achieved?
4) Interpretation?
3) Information from waveforms/manoeuvres ?
Safe ventilation?Safe oxygenation?Other problems
Morning Ward Round
Ms Smith35yr old
Exacerbation of Asthma
PROBLEM WITH Resistance?
ET tubeIncreased airways resistance
PRESSURE TIME CURVEIncreased Airway Resistance
Values
Pattern
Increased PIP
Rapid rise in PIP. Then tapers down
Values
Pattern
Expiratory limb back to baseline
VOLUME MODE
Values
Pattern
FLOW TIME CURVEIncreased Airway Resistance
Values
Pattern
Decreased Expiratory flow rate
Increased expiratory timeRises to zero baseline just before next breath
VOLUME MODE
FLOW TIME CURVEAuto-PEEP
Values
Pattern
Decreased Expiratory flow rate
Increased expiratory timeDoes not reach baselineAUC exp< inp
VOLUME MODE
Values
Pattern
No Change
35 year old lady with respiratory failure 2’ to exacerbation of Asthma
Currently intubated
Weight 80kg (Predicted body weight)
History
Examination
Examination
INFUSIONS:
Morphine 10mg/hrMidazolam: 10mg/hrNoradrenaline : 2 mcg/min
PHYSICAL EXAM
ETT Size 8.5Trachea midlineB/L expiratory wheeze
Investigation
Ventilator
What mode
Parameters set and achievedOxygenationVentilation
Interpretation
Waveforms
MODE
The Ventilator
Parameters achieved
15
Parameters set
Information from waveforms
The Ventilator
IncreaseEarly Peak pressures
DECREASEExpiratory flow rate
INCREASEExpiratory time
Inspiratory pause
Expiratory pause
Raised Peak pressure
Plateau pressure normal
No intrinsic PEEP
PcmH20
Time
INTERPRETATION
IS VENTILATION SAFE?
IS OXYGENATION SAFE?
Other problems?
Safe ventilation?TV 6-8ml/kgPplat<30
Safe oxygenation?FiO2<60%
Other problems:Low ComplianceHigh Resistance
INCREASED AIRWAY RESISTANCENO gas trapping
MANAGE Patient
MANAGE Ventilator
BronchodilatorsSteroidsAntibiotics
Monitor for gas trap
Emergency buzzer
PHYSICAL EXAM
Trachea midlineDiminished breath sounds
Parameters achieved
Parameters set
MODE
Volume mode
F 18, TV 500, Flow 70, FiO2 35%, PEEP 0
Peak pressure 55, I:E 1:4, Volume 430
Information from waveforms
Expiratory pause
INTERPRETATION
IS VENTILATION SAFE?
IS OXYGENATION SAFE?
Other Problems?
Gas trapping
Safe ventilation?TV 6-8ml/kgPplat<30
Safe oxygenation?FiO2<60%
Other problems:Low ComplianceHigh ResistanceDyssynchronyEquipment
MANAGE Patient
MANAGE Ventilator
Disconnect patient Consider and correct
Hypovolemia, Pneumothorax
Disconnect patient.
Decreased RRIncrease Insp flow rateProlonged I:E
A) Patient AssessmentReport ECG findingsDesc
ribeInterpret
Patient Assessment
B) Technical qualityC) Report Ventilator findings
1) Mode?
2) Parameters set and achieved?
4) Interpretation?
3) Information from waveforms/manoeuvres ?
Safe ventilation?Safe oxygenation?Other problems
Read Ventilator – daily patient assessmentHave a System
Modes of Ventilation
Loops
Dyssynchrony
Waveform abnormalities
PEEP/ Recruitment
A) Patient AssessmentReport ECG findingsDesc
ribeInterpret
Patient Assessment
B) Technical qualityC) Report Ventilator findings
1) Mode?
2) Parameters set and achieved?
4) Interpretation?
3) Information from waveforms/manoeuvres ?
Safe ventilation?Safe oxygenation?Other problems
8th Alfred Advanced Mechanical Ventilation Conference (AAMVC) Waveforms Workshop & Physiotherapy MeetingWednesday, 16 July, 2014 - Friday, 18 July, 2014
ReferencesCritical Care Medicine Tutorialshttp://www.ccmtutorials.com/rs/mv/
Puritan Bennett™ , 840 Ventilator, User’s Pocket Guidehttp://www.covidien.com/imageServer.aspx/doc228227.pdf?contentID=26430&contenttype=application/pdf
Curves and loops in mechanical ventilationhttp://www.draeger.net/media/10/08/41/10084127/rsp_curves_and_loops_booklet_9097339_en.pdf
http://lifeinthefastlane.com/education/ccc/pressure-vs-time-graph/
Oh's Intensive Care Manual, 6eAndrew D Bersten, Neil Soni
Report ECG findingsDesc
ribeInterpret
Patient Assessment
THANK YOU
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