ventilator graphics

Essentials of Ventilator Graphics ©2000 RespiMedu

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)

Flow

(L/m

in) InspirationInspiration

ExpirationExpiration


Mechanical BreathMechanical Breath

Inspiration

Expiration

Flow

(L/m

in)

Time (sec)


Typical Flow PatternsTypical Flow Patterns

ACCELERATINGACCELERATINGACCELERATINGACCELERATING

DECELERATINGDECELERATINGDECELERATINGDECELERATING

SINESINESINESINE

SQUARESQUARESQUARESQUARE


Inspiratory Flow Pattern Inspiratory Flow Pattern

Inspiration

Expiration

Time (sec)

Flo

w (

L/m

in)

Flo

w (

L/m

in)

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)

Flo

w (

L/m

in)

Beginning of expirationexhalation valve opens

Peak Expiratory Flow RatePEFR

Duration of expiratory flow

Expiratory time

TE


Inspiratory PauseInspiratory Pause

Inspiration

Expiration

Flow

(L/m

in)

Time (sec)}

pause


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)

Flo

w (

L/m

in)

Air TrappingAuto-PEEP

}


Response to BronchodilatorResponse to Bronchodilator

Before

Time (sec)

Flo

w (

L/m

in)

PEFR

After

Long TE

Higher PEFR

Shorter TE


SCALARS


Volume/Time


Volume vs TimeVolume vs Time

InspirationInspiration

Expiration

Time (sec)Time (sec)

Vo

lum

e (m

l)V

olu

me

(ml)

Inspiratory Tidal Volume

TTII


Air Leak/Air Trapping


Vo

lum

e (m

l)V

olu

me

(ml)


Volume lostVolume lost


SCALARS


Volume/Time


Spontaneous BreathSpontaneous BreathPP

awaw (

cm H

(cm

H220

)0)


InspirationInspiration



Mechanical BreathMechanical Breath

InspirationExpirationP

aw

(cm

H2O

)

Time (sec)

}}TI

Peak Inspiratory PressurePIP

PEEPPEEP

TE


Mechanical

Time (sec)

Pa

w

(cm

H2O

)

Time Triggered Breath

CONTROLLED BREATH(Time Triggered)


Assisted Breath(Patient Triggered)

Assisted Breath(Patient Triggered)

Mechanical

Time (sec)

Pa

w

(cm

H2O

)

Patient Triggered Breath


Assisted vs ControlledAssisted vs Controlled

Time (sec)

Assisted ControlledPressure (cmH20)


Spontaneous vs. MechanicalSpontaneous vs. Mechanical

MechanicalMechanical

Time (sec)

SpontaneousSpontaneous

Pa

w (

cm H

2O

)

Inspiration


Inspiration


Components of Inflation PressureComponents of Inflation Pressure

Begin Expiration

Pa

w

(cm

H2O

)

Time (sec)

Begin Inspiration

PIPPIP

Pplateau

(Palveolar)

Transairway Pressure (PTA)}}

Exhalation Valve Opens


Inspiratory Pause


Inadequate Inspiratory Flow

Adequate Flow

Time (sec)

Inadequate Flow

Pa

w

(cm

H2O

)



LOOPS


Pressure-Volume Loop

(Type of Breath)

Pressure-Volume Loop

(Type of Breath)

Controlled Assisted Spontaneous

Vol (m

l)

Paw

(cm H2O)

I: InspirationE: Expiration

I

E

E

E

II


Components of Pressure-Volume Loop

Components of Pressure-Volume Loop

Volume Volume (mL)(mL)

Insp

irat

ion

Expirat

ion

PIP

VT

PPawaw (cm H (cm H22O)O)


PEEP and P-V LoopPEEP and P-V Loop

Volume (mL)

VT

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)

BBBB

AAAA


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




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




Volume (mL)Volume (mL)

Preset PIP

VT

levels




Pre

ssu

re T

arg

ete

d

Ven

tilatio

n


OverdistensionOverdistension

Volu

me (

ml)

Pressure (cm HPressure (cm H22O)O)

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

Paw risesPaw

rises

NormalAbnormal



LOOPS


Flow-Volume LoopFlow-Volume Loop

Volume (ml)Volume (ml)

PEFR

FRC

Inspiration

Expiration

Flo

w (

L/m

in)

Flo

w (

L/m

in) PIFR

VT


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

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

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)

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)

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)

SIMV(Volume-Targeted Ventilation)

Spontaneous Breaths

Pressure

Flow

Volume

(L/min)

(cm H2O)

(ml)


Controlled Mode (Pressure-Targeted Ventilation)

Controlled Mode (Pressure-Targeted Ventilation)

Pressure

Flow

Volume

(L/min)

(cm H2O)

(ml)


Time-Time-Cycled

Set PC level

Time Triggered, Pressure Limited, Time Cycled Ventilation


Assisted Mode (Pressure-Targeted Ventilation)

Assisted Mode (Pressure-Targeted Ventilation)

Pressure

Flow

Volume

(L/min)

(cm H2O)

(ml)

Set PC level


Time-Cycled

Patient Triggered, Pressure Limited, Time Cycled Ventilation


Pressure

Flow

Volume

(L/min)

(cm H2O)

(ml)

Set PC levelSet PC level


SIMV Mode (Pressure-Targeted Ventilation)

SIMV Mode (Pressure-Targeted Ventilation)

Spontaneous Breath


Pressure

Flow

Volume

(L/min)

(cm H2O)

(ml)

SIMV + PS (Pressure-Targeted Ventilation)

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)

SIMV+PS(Volume-Targeted Ventilation)

Flow

Pressure

Volume

(L/min)

(cm H2O)

(ml)

Set PS level

PS Breath

Flow-cycled


Pressure

Flow

Volume

(L/min)

(cm H2O)

(ml)

Set PC levelSet PC level


SIMV + PS + CPAP (Pressure-Targeted Ventilation)

SIMV + PS + CPAP (Pressure-Targeted Ventilation)

Set PS level

CPAP levelCPAP level


SIMV+PS + CPAP(Volume-Targeted Ventilation)

SIMV+PS + CPAP(Volume-Targeted Ventilation)

Flow

Pressure

Volume

(L/min)

(cm H2O)

(ml)

Set PS level

CPAP levelCPAP level

Time (sec)

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