ventilator graphics

Ruben D Restrepo, MD, RRT, FAARCProfessor

The University of Texas Health Science Center at San Antonio

Objectives

Identify graphic display options Identify graphic display options provided by mechanical ventilators.provided by mechanical ventilators.

Describe how to use graphics toDescribe how to use graphics to more appropriately adjust the patient more appropriately adjust the patient

ventilator interface.ventilator interface.

Introduction

Monitoring and analysis of graphic Monitoring and analysis of graphic display of curves and loops during display of curves and loops during mechanical ventilation has become mechanical ventilation has become critical to determine critical to determine how patient is being ventilated how patient is being ventilated to assess problems occurring during to assess problems occurring during

ventilationventilation

Uses of Flow, Volume, and Pressure Graphic Displays

Confirm mode functionsConfirm mode functions Detect auto-PEEPDetect auto-PEEP Determine patient-ventilator synchronyDetermine patient-ventilator synchrony Assess and adjust trigger levelsAssess and adjust trigger levels Measure the work of breathingMeasure the work of breathing Adjust tidal volume and minimize overdistension Adjust tidal volume and minimize overdistension

Assess the effect of bronchodilator Assess the effect of bronchodilator

administrationadministration

Detect equipment malfunctionsDetect equipment malfunctions Determine appropriate PEEP levelDetermine appropriate PEEP level Evaluate adequacy of inspiratory time in Evaluate adequacy of inspiratory time in

pressure control ventilationpressure control ventilation Detect the presence and rate of continuous Detect the presence and rate of continuous

leaksleaks Assess inspiratory termination criteria during Assess inspiratory termination criteria during

Pressure Support VentilationPressure Support Ventilation Determine appropriate Rise Time Determine appropriate Rise Time

Uses of Flow, Volume, and Pressure Graphic Displays

GraphicsGraphicsSCALARS LOOPS

Flow/TimePressure/Time

Volume/Time

Pressure-Volume Flow-Volume

Volume/Time

Spontaneous BreathSpontaneous Breath

Time (sec)

in) InspirationInspiration

ExpirationExpiration

Mechanical BreathMechanical Breath

Inspiration

Expiration

Time (sec)

Typical Flow PatternsTypical Flow Patterns

ACCELERATINGACCELERATINGACCELERATINGACCELERATING

DECELERATINGDECELERATINGDECELERATINGDECELERATING

SINESINESINESINE

SQUARESQUARESQUARESQUARE

Inspiratory Flow Pattern Inspiratory Flow Pattern

Inspiration

Expiration

Time (sec)

Beginning of inspirationexhalation valve closes

Peak inspiratory flow ratePIFR

Beginning of expirationexhalation valve opens

Total cycle timeTCT

Insp. timeTI

Expiratory Time TE

Expiratory Flow PatternExpiratory Flow Pattern

Inspiration

Expiration

Time (sec)

Beginning of expirationexhalation valve opens

Peak Expiratory Flow RatePEFR

Duration of expiratory flow

Expiratory time

Inspiratory PauseInspiratory Pause

Inspiration

Expiration

Time (sec)}

Inadequate Inspiratory FlowInadequate Inspiratory Flow

Flow (L/min)

Time (sec)

NormalAbnormal

Active Active InspirationInspiration

Patient’s effort

Air TrappingAir Trapping

Inspiration

Expiration

NormalNormalPatientPatient

Time (sec)

Air TrappingAuto-PEEP

Response to BronchodilatorResponse to Bronchodilator

Before

Time (sec)

Long TE

Higher PEFR

Shorter TE

SCALARS

Volume/Time

Volume vs TimeVolume vs Time

InspirationInspiration

Expiration

Time (sec)Time (sec)

Inspiratory Tidal Volume

Air Leak/Air Trapping

Volume lostVolume lost

SCALARS

Volume/Time

Spontaneous BreathSpontaneous BreathPP

awaw (

InspirationInspiration

Mechanical BreathMechanical Breath

InspirationExpirationP

Time (sec)

Peak Inspiratory PressurePIP

PEEPPEEP

Mechanical

Time (sec)

Time Triggered Breath

CONTROLLED BREATH(Time Triggered)

Assisted Breath(Patient Triggered)

Mechanical

Time (sec)

Patient Triggered Breath

Assisted vs ControlledAssisted vs Controlled

Time (sec)

Assisted ControlledPressure (cmH20)

Spontaneous vs. MechanicalSpontaneous vs. Mechanical

MechanicalMechanical

Time (sec)

SpontaneousSpontaneous

Inspiration

Components of Inflation PressureComponents of Inflation Pressure

Begin Expiration

Time (sec)

Begin Inspiration

PIPPIP

Pplateau

(Palveolar)

Transairway Pressure (PTA)}}

Exhalation Valve Opens

Inspiratory Pause

Inadequate Inspiratory Flow

Adequate Flow

Time (sec)

Inadequate Flow

Pressure-Volume Loop

(Type of Breath)

Pressure-Volume Loop

(Type of Breath)

Controlled Assisted Spontaneous

Vol (m

(cm H2O)

I: InspirationE: Expiration

Components of Pressure-Volume Loop

Volume Volume (mL)(mL)

Expirat

PPawaw (cm H (cm H22O)O)

PEEP and P-V LoopPEEP and P-V Loop

Volume (mL)

PIPPIPPaw (cm H2O)

PEEP PEEP

Work of BreathingWork of Breathing

A: Resistive Work B: Elastic Work A: Resistive Work B: Elastic Work

Pressure (cm H2O)

Volume (ml)

Inflection PointsInflection Points

Pressure (cm H2O)

Volume (mL)

Lower Inflection Point

Upper Inflection Points

Inadequate SensitivityInadequate Sensitivity

Volume Volume (mL)(mL)

PPawaw (cm H (cm H22O)O)Increased WOB

Air Leak/Air Trapping

Volume (ml)

Pressure (cm HPressure (cm H22O)O)

Air Leak

Inadequate Inspiratory FlowInadequate Inspiratory Flow

PPaw aw (cm (cm HH22O)O)

Volume Volume (ml)(ml)

NormalAbnormal

Active InspirationActive Inspiration

Inappropriate FlowInappropriate Flow

PPaw aw (cm (cm HH22O)O)

Volume Volume (ml)(ml)

Higher PTA

Increased RawIncreased Raw

Higher PTA

HysteresisHysteresis

Volume (ml)

Pressure (cm Pressure (cm HH22O)O)

Abnormal Hysteresis

Normal Hysteresis

Lung Compliance Changes and the P-V Loop

Volume (mL)Volume (mL)

PIP levels

Preset VT

COMPLIANCEIncreasedNormalDecreased

Volume Targeted Ventilation

Lung Compliance Changes and the P-V Loop

Volume (mL)Volume (mL)

Preset PIP

levels

COMPLIANCEIncreasedNormalDecreased

tilatio

OverdistensionOverdistension

Pressure (cm HPressure (cm H22O)O)

With little or no change in VTWith little or no change in VT

Paw risesPaw

NormalAbnormal

Flow-Volume LoopFlow-Volume Loop

Volume (ml)Volume (ml)

Inspiration

Expiration

in) PIFR

Air LeakAir LeakInspiration

Expiration

Volume (ml)

Flow Flow (L/min)(L/min)

Air Leak in mL

NormalAbnormal

Air TrappingAir Trapping

Inspiration

Expiration

Flow (L/min)

Does not returnDoes not returnto baselineto baseline

NormalAbnormal

Increased Airway ResistanceIncreased Airway Resistance

Inspiration

Expiration

VolumeVolume (ml) (ml)

Flow (L/min)

Decreased PEFR

NormalNormalAbnormal

“Scooped out” pattern

Airway Secretions/Condensate in the Circuit

Inspiration

Expiration

Flow (L/min)

NormalAbnormal

Modes of Ventilation

SpontaneousMechanical

Volume Targeted

PressureTargeted

Spontaneous Breath

Time (sec)

FlowL/m

Pressurecm H2O

VolumemL

CPAPCPAP

CPAP level

FlowL/m

Pressurecm H2O

VolumemL

PSVPSV

Time (sec)

FlowL/m

Pressurecm H2O

VolumemL

Flow CyclingFlow Cycling

Set PS level

Patient Triggered, Flow Cycled, Pressure limited Mode

CPAP + PSV CPAP + PSV

Set PS level

CPAP level

FlowL/m

Pressurecm H2O

VolumemL

Flow Cycling

Modes of Ventilation

Spontaneous Mechanical

Volume Targeted

PressureTargeted

Controlled Mode (Volume- Targeted Ventilation)

Preset VT

Volume Cycling

Dependent onCL & Raw

FlowL/m

Pressurecm H2O

VolumemL

Preset Peak Flow

Time triggered, Flow limited, Volume cycled Ventilation

Assisted Mode(Volume-Targeted Ventilation)

FlowL/m

Pressurecm H2O

VolumemL

Preset VT

Volume Cycling

Patient triggered, Flow limited, Volume cycled Ventilation

SIMV(Volume-Targeted Ventilation)

Spontaneous Breaths

Pressure

Volume

(L/min)

(cm H2O)

Controlled Mode (Pressure-Targeted Ventilation)

Pressure

Volume

(L/min)

(cm H2O)

Time-Time-Cycled

Set PC level

Time Triggered, Pressure Limited, Time Cycled Ventilation

Assisted Mode (Pressure-Targeted Ventilation)

Pressure

Volume

(L/min)

(cm H2O)

Set PC level

Time-Cycled

Patient Triggered, Pressure Limited, Time Cycled Ventilation

Pressure

Volume

(L/min)

(cm H2O)

Set PC levelSet PC level

SIMV Mode (Pressure-Targeted Ventilation)

Spontaneous Breath

Pressure

Volume

(L/min)

(cm H2O)

SIMV + PS (Pressure-Targeted Ventilation)

PS Breath

Set PS levelSet PC levelSet PC level

Time (sec)

Time-Cycled Flow-Cycled

SIMV+PS(Volume-Targeted Ventilation)

Pressure

Volume

(L/min)

(cm H2O)

Set PS level

PS Breath

Flow-cycled

Pressure

Volume

(L/min)

(cm H2O)

Set PC levelSet PC level

SIMV + PS + CPAP (Pressure-Targeted Ventilation)

Set PS level

CPAP levelCPAP level

SIMV+PS + CPAP(Volume-Targeted Ventilation)

Pressure

Volume

(L/min)

(cm H2O)

Set PS level

CPAP levelCPAP level

Time (sec)

THANK YOU NYC

ventilator graphics

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