BASICS OF WAVEFORM

INTERPRETATION
Michael Haines, MPH, RRT-NPS, AE-C

Objectives
Identify graphic display options
provided by mechanical ventilators.
Describe how to use graphics to
more appropriately adjust the patient
ventilator interface.

Monitoring and analysis of graphic display

of curves and loops during mechanical
ventilation has become a useful and popular
way to determine not only how patient are
being ventilated but also a way to assess
problems occurring during ventilation.

Uses of Flow, Volume, and

Pressure Graphic Display
Confirm mode functions

Detect auto-PEEP
Determine P-V synchrony
Assess and adjust trigger levels
Measure the work of breathing
Adjust tidal volume and minimize overdistension
Assess the effect of bronchodilator administration
Detect equipment malfunctions
Determine appropriate PEEP level

Uses of Flow, Volume, and

Pressure Graphic Display
Evaluate adequacy of inspiratory time in pressure
control ventilation
Detect the presence and rate of continuous leaks
Assess inspiratory termination criteria during
Pressure Support Ventilation
Determine appropriate Rise Time

The graphic display of flow, pressure and

volume is generally visualized in two
formats:

Waveforms
Loops

Most Commonly used

Waveforms
Pressure vs. Time
Flow vs. Time
Volume vs. Time

Pressure vs. Time Curve

30
A

C
PIP
Baseline

P
aw
cmH O

Mean Airway Pressure

Sec

1
-10

Pressure-Time Curve
20

Volume Ventilation

Pressure Ventilation

Paw

Expiration

cmH2O

Sec

PIP:

Pressure

compliance
resistance
volume
flow
PEEP

PEEP
time

No active breathing
Treats lung as single unit

PIP
resistance
flow

Pplat

end-inspiratory
alveolar pressure

compliance
tidal volume

PEEP

Work to Trigger
30

P
aw
cmH O

Sec

1
-10

Adequate Flow During

Volume-Control Ventilation
30

Adequate flow

Paw
cmH2O
1
-10

Time (s)

Inadequate Flow During

Volume-Control Ventilation

30

Adequate flow

Paw
cmH2O

Flow set too low

1
-10

Time (s)

Patient/Ventilator Synchrony
Volume Ventilator Delivering a Preset Flow and Volume

Adequate Flow

Paw

Sec

cmH2O
1

-20

Patient/Ventilator Synchrony
The Patient Outbreathing the Set Flow

Air Starvation

Paw

Sec

cmH2O
1

-20

Plateau Time
30

Inadequate plateau time

Paw
cmH2O

-20

SEC

Plateau Time
30

Adequate Plateau Time

Paw
cmH2O

-20

SEC

Flow vs.Time Curve

120
INSP

Inspiration

.
V

LPM

120

SEC

EXH

Flow vs.Time Curve

120
INSP

Inspiration

.
V

LPM

SEC

Expiration
120

EXH

Flow vs.Time Curve

120

Constant Flow

Descending Ramp
INSP

Inspiration

.
V

LPM

120

SEC

EXH

Flow-Time Curve
120
INSP

Insp. Pause

LPM

SEC

Expiration

120

EXH

Inspiratory Time
Short

Normal

Long

Expiratory Flow Rate and Changes

in Expiratory Resistance
120

SEC

LPM

-120

120

SEC

LPM

120

Obstructed Lung

Delayed flow return

Combined Screens
20

Volume Ventilation

Paw
cmH2O

Sec

V.

Pressure-Time and Flow-Time Curves

20

Volume Ventilation

Paw

Expiration

cmH2O

Sec

V.

Pressure-Time and Flow-Time Curves

Different Inspiratory Flow Patterns
20

Volume Ventilation

Paw

Expiration

Inspiration

cmH2O

Sec

V.

Pressure-Time and Flow-Time Curves

20

Pressure Ventilation

Volume Ventilation

Inspiratory Time

Paw
cmH2O

Sec

V.

Rise Time
Inspiratoty Rise Time Percentage
Flow Acceleration Percentage
How quickly inspiratory flow
accelerates to achieve set pressure.

Flow Acceleration Percent

Rise Time
Minimal Pressure Overshoot

P
Slow rise

Moderate rise

Fast rise

.
V
Pressure Relief
Time

Patient / Ventilator Synchrony

Volume Ventilation Delivering a Preset Flow and Volume

30

Adequate Flow

Paw

Sec

cmH2O
1

-20

Patient / Ventilator Synchrony

The Patient Is Outbreathing the Set Flow

30

Air Starvation

Paw

Sec

cmH2O
1

-20

What options do we have?

We Can Switch to a Decelerating Flow

Pattern: More Flow Up Front
120

.
V

SEC

LPM

-120

If Peak Flow Remains the Same, I-Time

Increases: Could Cause Asynchrony
120

.
V

SEC

LPM

-120

Changing Flow Waveform in Volume

Ventilation: Effect on Inspiratory Time
120

.
V

SEC

LPM

-120

Increased Peak Flow: Decreased

Inspiratory Time
120

.
V

SEC

LPM

-120

Detecting Auto-PEEP
120

.
V

SEC

LPM

Zero flow at end exhalation indicates

equilibration of lung and circuit pressure
-120

Note: There can still be pressure in the lung behind

airways that are completely obstructed

Detecting Auto-PEEP
120

.
V

SEC

LPM

120

The transition from expiratory to inspiratory

occurs without the expiratory flow returning
to zero

flow

Flow Waveform
inhalation

time

auto-PEEP

exhalation

PEEP
7 cm H2O

auto-PEEP
10 cm H2O

sensitivity
-1 cm H2O

auto-PEEP
3 cm H2O

sensitivity
-1 cm H2O

PEEP
10 cm H2O

PEEP
10 cm H2O

trigger effort = 11 cm H2O

trigger effort = 4 cm H2O

Auto-PEEP should be measured with set PEEP = 0

Volume vs.Time Curve

800 ml

Inspiration

VT

SEC

Volume vs.Time Curve

800 ml

Expiration
VT
SEC

Typical Volume Curve

I-Time
E-Time

1.2

A
VT
Liters

SEC

-0.4
A = inspiratory volume
B = expiratory volume

Air Trapping or Leaks

1.2
A

VT
Liters

SEC

-0.4
A = exhalation that does not return to zero

Loops

Pressure-Volume Loops
Flow-Volume Loops

Pressure-Volume Loop
VT
LITERS

0.6

0.4

0.2

Paw
cmH2O -60

40

20

20

40

60

Mandatory Breath
VT
LITERS

0.6

0.4

Inspiration
0.2

Paw
cmH2O -60

40

20

20

40

60

Mandatory Breath
VT

Counterclockwise

LITERS

0.6

Expiration
0.4

Inspiration
0.2

Paw
cmH2O -60

40

20

20

40

60

Spontaneous Breath
VT

Clockwise

LITERS

0.6

0.4

Inspiration

0.2

Paw
cmH2O -60

40

20

20

40

60

Spontaneous Breath
VT

Clockwise

LITERS

0.6

0.4

Inspiration

Expiration
0.2

Paw
cmH2O -60

40

20

20

40

60

Work of Breathing
VT
LITERS

0.6

0.4

0.2

Paw
cmH2O

-60

-40

-20

20

40

60

Assisted Breath
VT
LITERS

0.6

0.4

Assisted
Breath

0.2

Paw
cmH2O -60

40

20

20

40

60

Assisted Breath
VT
LITERS

0.6

0.4

Assisted
Breath

0.2

Inspiration

Paw
cmH2O -60

40

20

20

40

60

Assisted Breath
VT

Clockwise to Counterclockwise

LITERS

0.6

Expiration
0.4

Assisted
Breath

0.2

Inspiration

Paw
cmH2O -60

40

20

20

40

60

Pressure-Volume Loop Changes

VT
LITERS

0.6

0.4

0.2

Paw
cmH2O

-60

-40

-20

20

40

60

Changes in Compliances
VT
LITERS

Indicates a drop in compliance

(higher pressure for the same
volume)

0.6

0.4

0.2

Paw
cmH2O

-60

40

20

20

40

60

Lung Overdistension

Overdistension
VT

A = inspiratory pressure

LITERS

B = upper inflection point

0.6

C = lower inflection point

0.4

0.2

Paw
cmH2O

C
-60

-40

-20

20

40

60

Pressure Volume Loops

Pressure Volume Loops

Pressure Volume Loops

Flow -Volume Loops

Volume Control

Flow

Tidal Volume

Inspiration
Volume
Expiration

Flow -Volume Loops

Volume Control
Tidal Volume

Peak Inspiratory Flow

Flow

Peak Expiratory Flow

Inspiration
Volume
Expiration

ETT or Circuit Leaks

Obstructive Pattern

Bronchodilator Response
BEFORE
3
2

V
LPS
1
2
3

V
LPS

Bronchodilator Response
BEFORE

AFTER
Worse

V
LPS

V
LPS

Bronchodilator Response
BEFORE

AFTER
Better

Worse
3

3
INSP

V
LPS

V
LPS

V
LPS

VT

EXH

What Mode is This?

What Mode is This?

What Mode is This?

What Mode is This?

Remember
Waveforms and loops are graphical representation of the data collected by
the ventilator.
Typical Tracings
Pressure-time,
Flow-time,
Volume -time
Loops
Pressure-Volume
Flow-Volume
Assessment of pressure, flow and volume waveforms is a key aspect in the
management of the mechanically ventilated patient.

The End!