Mechanical Ventilation Graphical

Assessment
Mazen Kherallah, MD, MHA, FCCP
Assessing Mechanical Ventilation Waveforms

Normal Identifying Identifying Identifying

patterns, breath types breath
measurements sequence and problems:
mode of • Changing respiratory
operation mechanics
• Overdistention and
protective lung
strategy
• Dynamic
hyperinflation
syndrome
• Dys-synchrony
Assessing Mechanical Ventilation Waveforms

Normal Identifying Identifying Identifying

patterns, breath types breath
measurements sequence and problems:
mode of • Changing respiratory
operation mechanics
• Overdistention and
protective lung
strategy
• Dynamic
hyperinflation
syndrome
• Dys-synchrony
 50

Peak PAW
cmH2O Plateau PAW PAW
PRAW End Expiratory PAW

0
60 Inspiratory Flow Time Peak Inspiratory Flow

Inspiratory Hold Time Zero Flow at Plateau Phase

L/m 0 V°

Peak Expiratory Flow

-60
1

Inspiratory Time Expiratory Time Tidal Volume

L V

0
30

End Inspiratory Esophageal Pressure

cmH2O
Pes
0

End Expiratory Esophageal Pressure

-20
0 2 4 6 8 10 12 14 16 Seconds
 50

cmH2O PAW

0
60

L/m 0 V°

-60
0 2 4 6 8 10 12 14 16
Seconds
0.7 80

Flow (L/min)
Volume (L)

0 0.8

0
-80
-5 0 35
PAW (cm H2O) Volume (L)
 Peak Airway Pressure
Plateau Airway Pressure

0.7 80

Peak Inspiratory Flow

VT

Flow (L/min)
Volume (L)

Tidal Volume (VT)

Peak Expiratory Flow

0
End Expiratory Pressure
-80
-5 0 35 0 0.8
PAW (cm H2O) Volume (L)
Assessing Mechanical Ventilation Waveforms

Normal Identifying Identifying Identifying

patterns, breath types breath
measurements sequence and problems:
mode of • Changing respiratory
operation mechanics
• Overdistention and
protective lung
strategy
• Dynamic
hyperinflation
syndrome
• Dys-synchrony
 50
A B C D

cmH2O Pressure Limited PAW

0
Patient Triggered Patient Triggered Time Triggered
Patient Triggered
60
Flow Control Flow Control
Flow Cycled

L/m 0 V°

Patient’s Flow
-60
1

Patient’s Cycle Volume Cycle Time Cycle

L V

0
30

cmH2O
Pes
0

-20 Spontaneous Breath Supported Breath Assisted Breath Mandatory Breath

1 second
Assessing Mechanical Ventilation Waveforms

Normal Identifying Identifying Identifying

patterns, breath types breath
measurements sequence and problems:
mode of • Changing respiratory
operation mechanics
• Overdistention and
protective lung
strategy
• Dynamic
hyperinflation
syndrome
• Dys-synchrony
 50

cmH2O PAW

0
Continuous Mandatory Ventilation
50

cmH2O PAW

0
Intermittent Mandatory Ventilation
50

cmH2O PAW

0
Continuous Spontaneous Ventilation
 50

cmH2O PAW

0
60

L/m 0 V°

-60
1

L V

0
2 4 6 8 10 12 14 16 18

Seconds
 50

cmH2O PAW

0
60

L/m 0 V°

-60
1

L V

0
0 2 4 6 8 10 12 14 16

Seconds
 50

cmH2O PAW

0
60

L/m 0 V°

-60
1

L V

0
0 2 4 6 8 10 12 14 16

Seconds
Assessing Mechanical Ventilation
Waveforms

Normal Identifying Identifying Identifying

patterns, breath types breath
measurements sequence and problems:
mode of • Changing respiratory
operation mechanics
• Overdistention and
protective lung
strategy
• Dynamic
hyperinflation
syndrome
• Dys-synchrony
 50

cmH2O PAW

0
60

L/m 0 V°

-60
1

L V

0
30
↑R ↓Ccw ↓CLung ↑Flow ↓Clung+ ↑R
cmH2O
Pes Pes
0

-20 Before A B C D E
0 2 4 6 8 10 12 14 16 Seconds
Assessing Mechanical Ventilation Waveforms

Normal Identifying Identifying Identifying

patterns, breath types breath
measurements sequence and problems:
mode of • Changing respiratory
operation mechanics
• Protective lung
strategy
• Dynamic
hyperinflation
syndrome
• Dys-synchrony
Characteristic PV Changes in Injured Lungs
Optimal PEEP Pressure Limit

Protective Lung Strategy

Normal Lung
Volume (L)

C=dV/dP

UIP

ARSD

-5 0 LIP 40
PAW (cm H2O)
 50 Pressure Limit
Pressure Alarm Limit

cmH2O Pressure Adjusted 2-3 cm H2O each PAW

Pressure Maintained Pressure Decreased
5 cm H2O Test Breath breath to Achieve Target Volume

0
60

L/m 0 V°

-60
1

Higher Tidal Volume

Set Tidal Volume Tidal Volume Still Target Tidal Volume
L Lower than Target Achieved V
Low Tidal Volume

0
2 4 6 8 10 12 14 16 18

Seconds
Assessing Mechanical Ventilation Waveforms

Normal Identifying Identifying Identifying

patterns, breath types breath
measurements sequence and problems:
mode of • Changing respiratory
operation mechanics
• Overdistention and
protective lung
strategy
• Dynamic
hyperinflation
syndrome
• Dys-synchrony
 Effectiveness of medical resident education in
mechanical ventilation

33%

67%

Unable to Mange Auto PEEP Able to Manage Auto PEEP

Cox CE, Shannon S, Carson E, et al. Effectiveness of medical resident education in mechanical
20
ventilation. Am J Respir Crit Care Med 2003; 167: 32±8
 50

cmH2O PAW

0
60

L/m 0 V°

-60
1

L V

0
30

cmH2O
Pes Pes
0

-20
0 2 4 6 8 10 12 14 16 Seconds
 Paw Tracing in Dynamic Hyperinflation

50

es
cmH2O aews Pr PAW
PPr Pel
es
Pr Pel
PEEPi
0
0 2 4 6 8 10 12 14 16
Seconds
Normal Pattern Increased Airway Resistance Dynamic Hyperinflation

In the absence of patient’s efforts

 Dynamic Hyperinflation
80
Flow (L/min)

Volume (L)
Trapped Volume

Persistent Flow

-80 0.8
Response to Bronchodilators
80
Flow (L/min)

Volume (L)

Before

After

-80 0.8
Assessing Mechanical Ventilation Waveforms

Normal Identifying Identifying Identifying

patterns, breath types breath
measurements sequence and problems:
mode of • Changing respiratory
operation mechanics
• Overdistention and
protective lung
strategy
• Dynamic
hyperinflation
syndrome
• Dys-synchrony
Dual Pump System

Pump #1
MV

Pres

Pel

Pump #2
Patient
Schematic of inspiratory muscle activity (Pmus) on airway pressure and
Fow during mechanical ventilation in a volume preset mode.

20

(cm H2O)
Pao
10

0 Pump #1
MV
60
(liters/min)

Pres
Flow

-60
Pel
10
(cm H2O)
Pmus

Pump #2
0
Patient

-10
Assessing Mechanical Ventilation Waveforms

Normal Identifying Identifying Identifying

patterns, breath types breath
measurements sequence and problems:
mode of • Changing respiratory
operation mechanics
• Overdistention and
protective lung
strategy
• Dynamic
hyperinflation
syndrome
• Dys-synchrony
• Air Leak
 Expiratory Volumes and Air Leak

0.7 80

Inspiration

Flow (L/min)
Volume (L)

Volume
of Leak Expiration
Volume
of Leak
0

-80
-5 0 35 0 0.8
PAW (cm H2O) Volume (L)
 Thank You

Normal Identifying Identifying Identifying

patterns, breath types breath
measurements sequence and problems:
mode of • Changing respiratory
operation mechanics
• Overdistention and
protective lung
strategy
• Dynamic
hyperinflation
syndrome
• Dys-synchrony