MECHANICAL VENTILATION

Basics & Waveforms Interpretation

By Dr. HARDEEP
JUNIOR RESIDENT 2ND YEAR
INTERNAL MEDICINE
TERMS AND DEFINITIONS RELATED TO
MECHANICAL VENTILATION
 Definition of Pressures and Gradients
in the Lungs
Airway opening pressure (Pawo), is most often called mouth pressure (PM) or airway
pressure (Paw). Other terms that are often used to describe the airway opening pressure
include upper- airway pressure, mask pressure, or proximal airway pressure.
Unless pressure is applied at the airway opening, Pawo is zero or atmospheric pressure.

Intrapleural pressure (Ppl) is the pressure in the potential space between the parietal
and visceral pleurae. Ppl is normally about −5 cm H2O at the end of expiration during
spontaneous breathing. It is about −10 cm H2O at the end of inspiration.

Because Ppl is difficult to measure in a patient, a related measurement is used, the

esophageal pressure (Pes), which is obtained by placing a specially designed balloon in
the esophagus; changes in the balloon pressure
are used to estimate pressure and pressure changes in the pleural space.
 Transpulmonary pressure (PL or PTP), or transalveolar pressure, is the
pressure difference between the alveolar space and the pleural space
(Ppl): PL = Palv − Ppl.
alveolar inflation and is therefore sometimes called the alveolar
distending pressure. All modes of ventilation increase PL during
inspiration, either by decreasing Ppl (negative pressure ventilators) or
increasing Palv by increasing pressure at the upper airway (positive
pressure ventilators). The term transmural pressure is often used to
describe pleural pressure minus body surface pressure

Transthoracic pressure (PW) is the pressure difference

between the alveolar space or lung and the body’s surface
(Pbs): PW = Palv − Pbs. It represents the pressure required to
expand or contract the lungs and the chest wall at the same
time. It is sometimes abbreviated to PTT, meaning
transthoracic).
Transrespiratory pressure (PTR) is the pressure difference between the airway
opening and the body surface: PTR = Pawo − Pbs. Transrespiratory pressure is used
to describe the pressure required to inflate the lungs and airways during
positive pressure ventilation. In this situation, the body surface pressure (P bs) is
atmospheric and usually is given the value zero; thus P awo becomes the pressure
reading on a ventilator gauge (Paw).

Transairway pressure (PTA) is the pressure difference between the airway

opening and the alveolus: PTA = Paw − Palv. It is therefore the pressure gradient
required to produce airflow in the conductive airways. It represents the
pressure that must be generated to overcome resistance to gas flow in the
airways (i.e., airway resistance).
 LUNG CHARACTERISTICS
The compliance (C) of any structure
can be described as the relative ease
with which the structure distends. It
can be defined as the opposite, or
inverse, of elastance (e), where
elastance is the tendency of a
structure to return to its original
form after being stretched or acted
on by an outside force. Thus, C = 1/e
or e = 1/C.
Normal compliance in spontaneously
breathing patients: 0.05 to 0.17 L/cm H O
or 50 to 170 mL/cm H O
Normal compliance in intubated patients:
Males: 40 to 50 mL/cm H2O, up to
100 mL/cm H2O; Females: 35 to 45
mL/cm H2O, up to 100 mL/cm H2O
Resistance is a measurement of the
frictional forces that must be
overcome during breathing. These
frictional forces are the result of the
anatomical structure of the airways
and the tissue viscous resis- tance
offered by the lungs and adjacent
tissues and organs.
NORMAL RESISTANCE VALUES
Unintubated Patient
0.6 to 2.4 cm H2O/(L/s) at 0.5 L/s flow
Intubated Patient
Approximately 6 cm H2O/(L/s) or higher
(airway resistance increases as endotracheal
tube size decreases)
Measuring Lung Compliance Measuring Airway Resistance

• STATIC COMPLIANCE is measured when

Raw = (PIP − Pplateau)/flow
there is no airflow (using plateau pressure –
PEEP

• STATIC COMPLIANCE PTA = PIP − Pplateau.

= (exhaled tidal volume)/(plateau pressure
− EEP)
= VT/(Pplateau − EEP)

•DYNAMIC COMPLIANCE is measured

when airflow is present(using the peak
airway pressure- PEEP)

• DYNAMIC COMPLIANCE =
tidal volume / peak airway pressure- PEEP
 CLINICAL CONDITIONS THAT
AFFECT THE COMPLIANCE
DECREASED COMPLIANCE
STATIC DYNAMIC
Atelectasis Bronchospasm
ARDS Kinking of ET tube
Pneumothorax Airway obstruction
Obesity
Retained
secretions

INCREASED COMPLIANCE
Emphysema
Surfactant therapy
 NEGATIVE AND POSITIVE PRESSURE
VENTILATION
A. NEGATIVE PRESSURE VENTILATION
• Negative pressure ventilation creates a transairway
pressure gradient by decreasing the alveolar
pressures to a level below the airway opening
pressure (i. e., below the atmospheric pressure).
• Unless airway obstruction is present, negative
pressure ventilation does not require an artificial
airway.
• Two classical devices that provide negative pressure
ventilation are the “iron lung” and the chest cuirass
or chest shell
B. POSITIVE PRESSURE VENTILATION
• Positive pressure ventilation is achieved by
applying positive pressure (a pressure greater
than atmospheric pressure) at the airway
opening.
 TRIGGER VARIABLE
{beginning of inspiration}
TRIGGERING (INITIATION OF A BREATH)

• 1. Patient Triggered or Assisted Ventilation where a

mechanical breath results from an inspiratory effort
made by the patient.
• 2. Time Triggered or Controlled Ventilation is a term
used when a mechanical breath is generated by a timer
allowing delivery of breaths at fixed time intervals.
• For example, if the ventilator frequency is preset at 12
breaths per minute (60 sec), the time-triggering interval
for each complete breath is 5 sec.
• At this time-trigger interval, the ventilator automatically
delivers one mechanical breath every 5 sec without
regard to the patient’s breathing effort or requirement
• 3. Triggering can be secondary to a negative pressure
generated by the patient (Pressure triggering) or it
results when patient removes a specific amount of
flow from the circuit during inspiratory effort (Flow
triggering).
• For example, if the sensitivity for pressure triggering is
set at -3 cm H2O, then the patient must generate a
pressure of -3 cm H2O at the airway opening to trigger
the ventilator into inspiration.
• If the sensitivity for pressure triggering is changed from
-3 to -5 cm H2O, the ventilator becomes less sensitive
to the patient’s inspiratory effort as more effort is
needed to trigger the ventilator into inspiration.
• Changing the sensitivity from -3 to -5 cm H2O is
decreasing the sensitivity setting on the ventilator
• If the ventilator is made more sensitive to the
patient’s efforts (pressure, flow, or volume), it is
easier for the patient to trigger a breath. The
converse is also true.
• 4. Flow-Triggered. Some ventilators are able to
measure inspiratory and expiratory flows. When the
patient’s inspiratory flow reaches a specific value, a
ventilator-supported breath is delivered. Flow
triggering has been shown to be more sensitive and
responsive to a patient’s efforts than pressure
triggering.

• How hard the patient must work to initiate or trigger

a breath is termed the ventilator sensitivity.
 LIMIT VARIABLE (Safety)
• During a ventilator-supported breath, volume
pressure and inspiratory flow all rise above their
respective baseline values.
• Inspiratory time is defined as the time interval
between the start of inspiratory flow and the
beginning of expiratory flow.
• If one or more variables (pressure, flow, or volume) is
not allowed to rise above a preset value during the
inspiratory time, it is termed a limit variable.
 LIMIT VARIABLE
• 1 PRESSURE LIMIT
• 2 FLOW LIMIT
• 3 VOLUME LIMIT
 CYCLE VARIABLE
{Termination of Inspiration}
• 1. PRESSURE CYCLED
Inspiration is terminated when the preset pressure
reaches.

• 2. VOLUME CYCLED
Inspiration is terminated when the preset volume is
delivered by the ventilator.
• 3. Time-Cycled
When the preset inspiratory time elapses, inspiration is
terminated.

• 4. Flow-Cycled:
Inspiration is terminated when flow decreases to a
system specific flow rate.
The basic ventilator circuit diagram
 Ventilator Graphics
• Scalars
• Curves
• Loops
Types of Waveforms
 Pressure waveforms
• Square (constant)
• Exponential rise
• Sinusoidal

 Flow waveforms
• Descending ramp
• Square (constant)
• Exponential decay
• Sinusoidal
• Ascending ramp

 Volume waveforms
• Ascending ramp
• Sinusoidal
•Sinusoidal waves are seen with spontaneous, unsupported breathing.
Types of Waveforms
 Scalars: plot pressure/volume/flow against
time… time is the x axis
 Loops: plot pressure/volume/flow against
each other…there is no time component

 Six basic waveforms:

• Square: AKA rectangular or constant wave
• Ascending Ramp: AKA accelerating ramp
• Descending Ramp: AKA decelerating ramp
• Sinusoidal: AKA sine wave
• Exponential rising
• Exponential decaying
•Generally, the ascending/descending ramps are considered the same as the exponential
ramps.
 Scalars
• Scalars waveform representations of pressure, flow
or volume on the y axis vs time on the x axis
• Ventilators measure airway pressure and airway flow
• Volume is derived from the flow measurement
• Pressure and flow provide all the information
necessary to explain the physical interaction
between ventilator and patient
• Volume scalar – tidal volume delivered during
inspiration and expiration
Types of Waveforms
Volume Modes Pressure Modes

Pressur
Pressur

e
e

Flow
Flow

Volume
Volume

Volume Control/ SIMV (Vol. Control) Pressure Control/ PRVC Pressure Support/
SIMV (PRVC) Volume Support
SIMV (Press. Control)
Pressure/Time Scalar
• In Volume modes,  In Pressure modes, the
shape will be rectangular
the shape will be or square.
an exponential  This means that pressure
rise or an remains constant
accelerating ramp throughout the breath
for mandatory cycle.
breaths.

•In Volume modes, adding an inspiratory pause may improve distribution of ventilation.
Pressure/Time Scalar
Can be used to assess:
•Air trapping (auto-PEEP)
•Airway Obstruction
•Bronchodilator Response
•Respiratory Mechanics (C/Raw)
•Active Exhalation
•Breath Type (Pressure vs. Volume)
•PIP, Pplat
•CPAP, PEEP
•Asynchrony
•Triggering Effort
Pressure/Time Scalar
Inspiratory pause
1

A = MAP
B

1 = Peak Inspiratory Pressure (PIP)

2 = Plateau Pressure (Pplat)
A = Airway Resistance (Raw)
B = Alveolar Distending Pressure
• The area under the entire curve represents the mean airway pressure (MAP).
Pressure/Time Scalar

Increased Airway Resistance Decreased Compliance

A. B.
PIP PI
P
Pplat
Pplat

•A-An increase in airway resistance causes the PIP to increase, but Pplat pressure
remains normal.
•B-A decrease in lung compliance causes the entire waveform to increase in size.
The difference between PIP and Pplat remain normal.
Pressure-time waveforms using a
‘square wave’ flow pattern
Paw = Flow x Resistance + Volume
Compliance
#
1
pressure

Ppea Normal
k values:
Pre Ppeak < 40
s
cm H2O
Ppl Pplat < 30 cm
Pre at H2O Pres <
s
time 10 cm H2O

flow
Normal pressure-time waveform With tim
normal peak pressures ( Ppeak) ; plateau e

pressures (Pplat )and ‘Square

airway resistance pressures (Pres) wave’
Pressure-time waveform -
obstruction
Paw = Flow x Resistance + Volume + PEEP
Compliance

#
pressure

Ppea
Nor
mal
2
k

Pre e.g. ET
s
tube
blocka
Ppl ge
Pre at

flow
s
time
tim
Increase in peak airway e
pressure driven by an
‘Square
increase in the airways wave’
resistance normal flow
pattern
plateau pressure
ET Tube obstruction
 Pressure time waveform –high flow

#
pressure

Ppea Norm 3
al
k
e.g. high
Pre flow
s
rates
Ppl
at
Pre
s
time

flow
Increase in the peak airway pressure driven
entirely by an increase in the airways tim
resistance pressure caused by Normal e
excessive flow rates shortened (low)
inspiratory time and high flow flow ‘Square
wave’
rate
High airflow causing increase in airway
resistance
Pressure time waveform – reduced Compliance
Paw = Flow x Resistance + Volume + PEEP
Compliance
#
4
pressure

Norm
Ppeak al e.g.
ARDS
Pr
es

Ppl
at

Pre
time

flow
s

Increase in the peak airway tim

e
pressure is driven entirely by
the decrease in the lung ‘Square
compliance wave’
Reduced compliance
 Comparison
Normal High Raw:
Hig COPD
Nor h
ma PI
l P
PIP
Nor Nor
ma ma
l l
Pplat Ppla
t

High flow: Hig

Hig
(short
h Low
h PI
PI Inspiratory P Complia
P
time) nce
: ARDS
Hig
Norm h
al
Ppla
Pplat t
 Stress index – Pressure time
waveform
• At constant flow, the slope of the airway pressure-
time curve is proportional to elastance (inversely
proportional to resistance)
• In passively breathing patients and at constant flow –
shape of the pressure time curve provide overview about
compliance/recruitable/overdistension
• When rate of pressure increase with time is small
indicating a recruitable lung (Curve convex
upwards)
• When rate of pressure change is higher indicating
overdistention
Stress index :Pressure time waveform
 Stress index can be accurately
determined by visual inspection

Mie Sun et al Respiratory Care June 2018,

 Overdistension
• Stress index upward concavity of the pressure time scalar
• Increased Ppeak and Pplat
• High peak expiratory flow
 Mean airway pressure
• Average pressure over a ventilatory cycle (one
inspiration and one expiration)
• Area below the pressure-time curve divided by the
ventilatory period (inspiratory time plus expiratory time)
• Numerically, calculated as the average of many
pressure samples taken over the ventilatory period
• PaO2 is proportional to mean airway pressure
• Cardiac output may be inversely proportional
• Increase airway pressure or increases the I:E ratio (increasing
inspiratory time or decreasing expiratory time) increases
mean airway pressure
 Esophageal pressure curve
• Esophageal pressure is measured by a catheter
with a balloon that is placed at the lower end of
the esophagus
• Estimate the pleural pressure
• Passive patient esophageal pressure increases with
each mechanical insufflation
• Spontaneously breathing patients esophageal
pressure becomes negative during insufflation
• Positioning is key
Positioning esophageal balloon
Esophageal waveform in passive patient
Esophageal waveform in spontaneously
breathing individuals
• Starts decreasing at the onset of the patient’s
inspiratory effort and drops to a minimum
pressure at the end of the inspiratory effort
 Clinical application
• Measuring transpulmonary pressure at end inspiration and expiration
• Open lung strategy in ARDS ventilation and prevention of lung injury
• End inspiratory transpulmonary pressure ≤ 25 (≤ 20 cm)
• End expiratory transpulmonary pressure 0-5 cm
• Spontaneously breathing
• Inspiratory effort
• AutoPEEP
• Asynchrony assessment
 Volume/Time Scalar

The Volume waveform will generally have a “mountain peak”

appearance at the top. It may also have a plateau, or “flattened”
area at the peak of the waveform.

•There will also be a plateau if an inspiratory pause set or inspiratory hold maneuver is
applied to the breath.
 Volume/Time Scalar
Can be used to assess:

•Air trapping (auto-PEEP)

•Leaks

•Tidal Volume
•Active Exhalation
•Asynchrony
Volume/Time Scalar

Inspiratory Tidal Volume

Exhaled volume returns

to baseline
 Volume/Time Scalar

Air-Trapping or Leak

Loss of volume

•If the exhalation side of the waveform doesn’t return to baseline, it could be
from air-trapping or there could be a leak (ETT, vent circuit, chest tube,
etc.)
 Flow/Time Scalar

• In Pressure modes,
 In Volume modes, the shape of the
waveform will be square or (PC, PS, PRVC)
rectangular. • the shape of the
waveform will have a
 This means that flow remains
constant throughout the decelerating ramp
breath cycle. flow pattern.
Iyer et al. ATS review: Ventilator waveform
Iyer et al. ATS review: Ventilator waveform
 Flow/Time Scalar

Can be used to assess:

•Air trapping (auto-PEEP)

•Airway Obstruction
•Bronchodilator Response
•Active Exhalation
•Breath Type (Pressure vs. Volume)
•Flow Waveform Shape
•Inspiratory Flow
•Asynchrony
•Triggering Effort
 Flow/Time Scalar

Volume Pressur
e
 Flow/Time Scalar

•The decelerating flow pattern may be preferred over the constant flow pattern. The same
tidal volume is delivered, but with a lower peak pressure.
 Flow/Time Scalar

Auto-Peep (air trapping)

=
Normal
Expiratory flow
doesn’t return to
baseline

Start of next breath

•If expiratory flow doesn’t return to baseline before the next breath starts, there’s auto-
PEEP (air trapping) present , e.g. emphysema.
 Auto P EEP
• Expiration is interrupted before its natural end by
the next inspiration some un-expired residual gas
remains in thorax
• Exerts a pressure onto the respiratory circuit
• As a result, the alveolar pressure at the end of
expiration is higher than zero (atmospheric
pressure = 0)
• This incomplete emptying is called dynamic
hyperinflation, and the positive alveolar pressure
is called PEEPi or auto PEEP
Auto P EEP
 Auto P EEP consequences
• Ineffective
triggers
• Increased WOB
• Hypoxia
• Barotrauma
• Hemodynamic
instability
 Auto P EEP Detection
• End-expiratory occlusion is used to measure auto
PEEP
• Pressure in the lungs equilibrates with the pressure
ventilator circuit
• Pressure measured at the proximal airways is
equal to the end- expiratory alveolar
pressure
• Auto PEEP is the difference between total PEEP
and set PEEP
Auto P EEP Detection
 Overcoming Auto P EEP
• Decrease
• Insp time
• RR
• Vt
• Resp demand – pain fever anxiety
• Bronchodilator use
• External PEEP
 Flow/Time Scalar

Bronchodilator Response
Pre-Bronchodilator Post-Bronchodilator

Longer Shorte
E- r E-
time time

Peak Exp. Flow

Improved Peak Exp. Flow

•To assess response to bronchodilator therapy, you should see an increase in peak
expiratory flow rate.

•The expiratory curve should return to baseline sooner.

 Zero flow state

•Notice the area of no flow indicated by the red line. This is known as a “zero-flow
state”.
Waveforms observed in pressure
support
• Flow or pressure triggered, pressure targeted and
flow cycled
• Pressure curve may be shaped by a set rise time
• Flow curve characteristics determined by
Inspiratory time constant (compliance,
resistance) and patients effort
 Rise Time &
Inspiratory Cycle Off %
SIMV
Waveforms observed in pressure support
 Rise Time
•The inspiratory rise time determines the amount of
time it takes to reach the desired airway pressure or
peak flow rate.

•Used to assess if ventilator is meeting patient’s demand in Pressure Support

mode.
•In SIMV, rise time becomes a % of the breath cycle.
 Rise Time

pressure spike

too fast too slow

 If rise time is too fast, you can get an overshoot in the pressure wave,
creating a pressure “spike”. If this occurs, you need to increase the rise
time. This makes the flow valve open a bit more slowly.
 If rise time is too slow, the pressure wave becomes rounded or
slanted, when it should be more square. This will decrease Vt delivery
and may not meet the patient’s inspiratory demands. If this occurs,
you will need to decrease the rise time to open the valve faster
 Hence rise time is set according to patients demand.
 Inspiratory Cycle Off
•The inspiratory cycle off determines when the
ventilator flow cycles from inspiration to expiration, in
Pressure Support mode.

Also know as–

•Inspiratory flow termination,
•Expiratory flow sensitivity,
•Inspiratory flow cycle %,
•E-cycle etc…

•The flow-cycling variable is given different names depending on the type of ventilator.
 Inspiratory Cycle Off
Inspiration ends

pressur
e

flow

•The breath ends when the ventilator detects inspiratory flow has dropped to a specific
flow value.
 Inspiratory Cycle Off

100% of Patient’s
Peak Inspiratory Flow
100
%
75%
Flow

50%
30%

•In the above example, the machine is set to cycle inspiration off at 30% of the patient’s
peak inspiratory flow.
 Inspiratory Cycle Off
Exhalatio
A B
n spike

100 100
% %
60
% 10
%

•A –The cycle off percentage is too high, cycling off too soon. This makes the breath too
small. (not enough Vt.)
•B – The cycle off percentage is too low, making the breath too long. This forces the
patient to actively exhale (increase WOB), creating an exhalation “spike”.
Waveforms observed in pressure support
Identifying Trigger and flow Related
problems via scalars
 Early cycling

• Flow from ventilator ends but patient still making

insp effort
• Distortion of flow and pressure wave form at onset of
expiration
• Abrupt initial reversal of expiratory flow toward zero,
indicating patient’s inspiratory effort is prolonged
• Exaggeration of same = autotrigger
Early cycling
 Ineffective trigger
• Respiratory muscular effort which is insufficient to initiate
mechanical breath
• Manifests as a decrease in airway pressure associated
with a simultaneous increase in airflow
• Ventilator factors– effort not able to meet the set trigger,
large pressure drops across smaller tubes
• Patient related- Auto PEEP, resp muscle weakness and
decreased drive
Ineffective trigger
 Auto trigger
• Assisted breaths delivered which were not patient triggered
• Cause
• Fluid in circuit, leak, cardiac oscillations, low trigger threshhold
 Double trigger
• Patients inspiration continues after the
ventilator inspiration and triggers another
breath immediately after the inspiration
• High ventilatory demand of the patient (ARDS)
• Inappropriate settings ( Low tidal volume, short
inspiratory time, high ETS)
Double trigger
 Reverse triggering
• Unique type asynchrony in which diaphragmatic muscle
contractions triggered by ventilator insufflations constitute
a form of patient- ventilator interaction referred to as
“entrainment”
• In heavily sedated patients it is suggested that
patients had entrainment of neural breaths
within mandatory breaths.
• This entrainment occurred at a ratio of 1:1 up to 1:3.
They occur at the transition from the ventilator
inspiration to expiration.
• Breath stacking , overdistention and VIDD
 Reverse triggering

Mechanical ventilation-induced reverse-triggered breaths: a frequently unrecognized form of

neuromechanical coupling. Chest. 2013 Apr; 143(4):927-38
 Flow Asynchrony
• Causes :
• High ventilatory demand (ALI/ARDS)
• Low ventilatory settings ( flow rate, Vt, Pramp)
• Treatment:
• Treat reversible causes (fever, acidosis)
• Increase the Vt
• Increase the flow rate ( directly, or by decreasing
inspiratory time, increasing
pause)
• Change to pressure control mode with variable flow
Flow asynchrony

Patient with ARDS weaning

Loops
Pressure/Volume Loops

500

250

5 15 30
Pressure/Volume Loops

 Volume is plotted on the y-axis, Pressure on the x-

axis.
 Inspiratory curve is upward, Expiratory curve is
downward.
 Spontaneous breaths go clockwise and positive
pressure breaths go counterclockwise.
 The bottom of the loop will be at the set PEEP level.
It will be at 0 if there’s no PEEP set.
 If an imaginary line is drawn down the middle of
the loop, the area to the right represents inspiratory
resistance and the area to the left represents
expiratory resistance.
PV Loop in VCV
PV Loop in PCV
PV Loop in CPAP
Pressure/Volume Loops

Dynamic
Complianc
B e
B = Exp. (Cdyn)
500 n A=
atio
Resistance/ pir Inspiratory
ex A
Elastic WOB Resistance/
tion Resistive WOB
p ira
250 ins

5 15 30

•The top part of the P/V loop represents Dynamic compliance (Cdyn).
• Cdyn = Δvolume/Δpressure
Pressure/Volume Loops
Can be used to assess:

•Lung Overdistention
•Airway Obstruction
•Bronchodilator Response
•Respiratory Mechanics (C/Raw)
•WOB
•Flow Starvation
•Leaks
•Triggering Effort
 Pressure/Volume Loops
Overdistention

“beaking”

500

250

5 15 30

•Pressure continues to rise with little or no change in volume, creating a “bird beak”.
•Fix by reducing amount of tidal volume delivered
 Pressure/Volume Loops
Airway Resistance

nce
500 a
sist
re
p.
ex
sis”
e
er
t
ys
250 “h ce
an
sist
. re
p
ins
5 15 30

•As airway resistance increases, the loop will become wider.

•An increase in expiratory resistance is more commonly seen. Increased inspiratory
resistance is usually from a kinked ETT or patient biting.
Pressure/Volume Loops

Increased Decreased
Compliance Compliance

500 500

250 250

15 30 15 30

Example: Emphysema, Example: ARDS, CHF,

Surfactant Therapy Atelectasis
Pressure/Volume Loops
A Leak

500

250

5 15 30

•The expiratory portion of the loop doesn’t return to baseline. This indicates a leak.
 Pressure/Volume Loops
Inflectio
n Points

500

250

5 15 Lower 30

Inflection Point
•The lower inflection point represents the point of alveolar opening (recruitment).
•Some lung protection strategies for treating ARDS, suggest setting PEEP just above the
lower inflection point.
Point of upper inflection (Ipu)

 C lt changed later during

Vt because of
overinflation of the alveoli
 The reduction in Clt late
in inspiratory cycle is
called Ipu
 The appearance of upper
shape PAO curve
indicating the presence
of Ipu is known as duck
bill PVC
 Flow/Volume Loops
60

40

20

0
200 400 600

-20

-40

-60
Flow/Volume Loops

 Flow is plotted on the y axis and volume on the x axis

 Flow volume loops used for ventilator graphics are
the same as ones used for Pulmonary Function
Testing, (usually upside down).
 Inspiration is above the horizontal line and expiration is
below.
 The shape of the inspiratory curve will match what’s set on
the ventilator.
 The shape of the exp flow curve represents passive
exhalation…it’s long and more drawn out in patients with
less recoil.
 Can be used to determine the PIF, PEF, and Vt
 Looks circular with spontaneous breaths
Flow/Volume Loops
Flow/Volume Loops

Volume control Pressure Control

•The shape of the inspiratory curve will match the flow setting on the ventilator.
Flow/Volume Loops
In positive pressure ventilation(VC)

60

40

20
Start of Start of
Inspiratio Expiratio
0 n n
600
200
400
-20

-40

-60
PE
F
Flow/Volume Loops
In positive pressure ventilation(PC)
Flow/Volume Loops
Can be used to assess:

•Air trapping
•Airway Obstruction
•Airway Resistance
•Bronchodilator Response
•Insp/Exp Flow
•Flow Starvation
•Leaks
•Water or Secretion accumulation
•Asynchrony
Flow/Volume Loops
Air Leak
60

=
40 Normal

20

0
200 400 600

Expiratory -20
portion of loop
does not -40
return to starting
point, indicating
-60
a leak.

•If there is a leak, the loop will not meet at the starting point where inhalation starts and
exhalation ends. It can also occur with air-trapping.
Air Leak
Flow/Volume Loops
Airway Obstruction

Reduce
“scooping” d PEF

•The F-V loop appears “upside down” on most ventilators.

•The expiratory curve “scoops” with diseases with small airway obstruction (high
expiratory resistance). e.g. asthma, emphysema.
Obstructive Lung Disease Restrictive Lung Disease
 Air Trapping (auto-PEEP)

• Insufficient expiratory time
Causes:
• Early collapse of unstable alveoli/airways during exhalation

 How to Identify it on the

• Pressure wave: while performing an expiratory hold, the waveform rises
graphics
above baseline.
• Flow wave: the expiratory flow doesn’t return to baseline before the next
breath begins.
• Volume wave: the expiratory portion doesn’t return to baseline.
• Flow/Volume Loop: the loop doesn’t meet at the baseline
• Pressure/Volume Loop: the loop doesn’t meet at the baseline
Airway Resistance Changes

• Bronchospasm
Causes:
• ETT problems (too small, kinked, obstructed, patient biting)
• High flow rate
• Secretion build-up
• Damp or blocked expiratory valve/filter
• Water in the HME
 How to Identify it on the graphics
• Pressure wave: PIP increases, but the plateau stays the same
• Flow wave: it takes longer for the exp side to reach baseline/exp flow rate
is reduced
• Volume wave: it takes longer for the exp curve to reach the baseline
• Pressure/Volume loop: the loop will be wider. Increase Insp. Resistance
will cause it to bulge to the right. Exp resistance, bulges to the left.
• Flow/Volume loop: decreased exp flow with a scoop in the exp curve
 How to fix
• Give a treatment, suction patient, drain water, change HME, change ETT,
add a bite block, reduce PF rate, change exp filter.
 Leaks
 Causes
• Expiratory leak: ETT cuff leak , chest tube leak, BP fistula, NG tube
in trachea
• Inspiratory leak:loose connections, ventilator malfunction, faulty
flow sensor
 How
Pressure wave: Decreased PIP
• it
to ID
• Volume wave: Expiratory side of wave doesn’t return to
• baseline Flow wave: PEF decreased
• Pressure/Volume loop: exp side doesn’t return to the
• baseline Flow/Volume loop: exp side doesn’t return to
 How baseline
to fix it
• Check possible causes listed above
• Do a leak test and make sure all connections are
tight
 Asynchrony

 Causes (Flow, Rate, or Triggering)

• Air hunger (flow starvation)
• Neurological Injury
• Improperly set sensitivity

 How
• to Identify it
Pressure wave: patient tries to inhale/exhale in the middle of the
waveform causing a dip in the pressure
•
Flow wave: patient tries to inhale/exhale in the middle of the
waveform, causing erratic flows/dips in the waveform

Pressure/Volume loop: patient makes effort to breath causing dips in

loop either Insp/Exp.

Flow/Volume loop: patient makes effort to breath causing dips in

loop.
 Asynchrony

Flow Starvation

•The inspiratory portion of the pressure wave shows a scooping or “dip”, due to
inadequate flow.
 Asynchrony
•How to fix it:
• Try increasing the flow rate, decreasing
the I-time, or increasing the set rate to
“capture” the patient.
• Change the mode - sometimes changing
from partial to full support will solve the
problem
If neurological, may need paralytic or
sedative
Adjust sensitivity
Asynchrony

F/V Loop P/V Loop

Trigger Asynchrony
thankyou