Ventilator Waveforms

Dr Barry Dixon
St.Vincent’s Hospital
Melbourne Australia

Acknowledgement
Prof Tuxen and Dr Paul Nixon The Alfred Hospital
Ventilator Waveforms Course

1
2
 Summary

• Recognise common modes of ventilation

• Identify inspiratory problems
• Identify expiratory problems
• Identify triggering problems

3
Ventilation Modes

4
Volume Control

• Set volume
• Set flow (square or ramp)
• Set inspiratory time
• Set PEEP
• Pressure varies
(depends on the compliance and resistance)
• Pressure wave up sloping
• Inspiratory pause
Volume Control

• Square flow pattern

• Descending ramp (lower peak pressure but longer inspiration time)
Pressure Control

• Set pressure levels

• Set inspiratory time
• No inspiratory pause
• Pressure constant
• Flow varies
• Volume varies
(depends on the lung compliance and resistance)
 Pressure Control

• Mandatory upper and lower pressure levels and breath rate, set inspiratory time
• If want higher tidal volume, set higher upper level or longer inspiratory time
 CPAP

• Only spontaneous breaths supported, no mandatory breaths

• Set upper and lower pressure levels
• High initial flow followed by decelerating flow
• The flow is terminated once it falls to a set percentage of the peak flow
 Synchronised Intermittent Mandatory Ventilation

• Volume control mode, Mandatory tidal volumes and breath rate

• Patients can trigger addition breaths above mandatory rate
• (A) Mandatory ventilator initiated breath (square flow wave)
• (B) patient initiated breath pressure support breath
• A pressure rise without an initial deflection below baseline represents a ventilator
initiated breath
• A small pressure drop just before a rise indicates a patients inspiratory effort and a
patient initiated breath.
Inspiratory problems

13
 Volume Control

• Increased Peak Pressure, but no change in Plateau

• Increased resistance in circuit or patients respiratory tree
• Bronchospasm, kinked tube, biting, sputum plug,
 Volume Control

• Increased Peak Pressure and increased Plateau pressure

• Decreased lung compliance
• ET tube in right main, pulmonary odema , pnueumothorax, sputum plugging
 Flow starvation

• M waves
• Bunny ears
• Dys-synchrony
• Fighting the ventilator
Flow starvation
Flow starvation
 Pressure Support- inadequate flow

• (A) acceleration in flow slow (may indicate flow is adequate - increase rise time)
• (B) Ideal square pressure waveform ( best patient comfort)
• (C) Quick rise time with overshoot in pressure (reduce rise Time)
Volume starvation
Volume starvation
Volume starvation
Expiratory problems

24
 Expiration

• Triangular shape
• Finished within 2 seconds
• 80% of volume out in first second
• flow reaches zero before next breath
 Bronchospasm

• flow drops dramatically and continuously as lungs become smaller

 Bronchospasm

• Assess bronchodilator response

• Higher initial expiratory peak flow
• More volume out in the first second
• Expiratory flow reaches zero earlier
Upper airway obstruction
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Blocked tubes
Upper airway obstruction
• During exhalation volume does not reach zero
• Consider air leak (et cuff, pneumothorax), air trapping due to bronchospasm,
volume sensor error
Triggering

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• The depth of the pressure drop below baseline and the time below baseline
indicates the patient’s effort to trigger a breath.
• If the changes are large may require a more sensitive trigger setting to reduce
the patient’s work of breathing
• Bronchospasm results in slow expiratory flows
• If expiration not complete before next breath gas trapping with auto PEEP
• Spontaneous breath may not trigger the ventilator as patient must overcome auto PEEP(A)

Treatment

• Bronchodilator
• Higher inspiratory flows to shorten inspiratory time and increase expiratory time
• Paralyse patient to stop wasted work
Triggering

Airway flow generated by

• cardiac pulsation
• air leak
• water bubbling in tubing

Treatment

• Check patient and circuit

• Less sensitive trigger
Reverse triggering
 Reverse triggering

Treatment

•Try waking if can

•Reduce sensitivity of the trigger
•Paralysis