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MECHANICAL

VENTILATION
DR. SHIVAM MOHAN PANDEY
Introduction

 Mechanical ventilation forms a mainstay of critical care in patients


with respiratory insufficiency.

 Ventilator must generate inspiratory flow to deliver tidal volume.

 Transairway pressure (PTA) = PAO – PALV

 PTA = 0, at the end of expiration and beginning of inspiration.

 Mechanical ventilator produce either negative or positive pressure


gradient.
Negative pressure
ventilation

 PTA gradient is created by decreasing PALV to below PAO


e.g.-
 Iron lungs
Disadvantages- poor patient access,
bulky size, cost, dec. cardiac output
(Tank shock).
 Chest cuirass or chest shell
Positive pressure ventilation

 Achieved by applying positive pressure at airway


opening which produces PTA gradient that generates
inspiratory flow.

 Inspiratory flow results in the delivery of tidal volume.


Indications and Rationale for Initiating IPPV
Unprotected and unstable airways (e.g,, coma)
• Intubation and IPPV allows to
- Secure the airways
- Reduce the risk of aspiration
- Maintain adequate alveolar ventilation

Hypercapnic respiratory acidosis


• IPPV and NIPPV
- Reduce the work of breathing and thus prevents respiratory muscle fatigue or speeds
recovery when fatigue is already present
- Maintain adequate alveolar ventilation (prevent or limit respiratory acidosis as
needed)

Hypoxic respiratory failure


• IPPV and NIPPV help correct hypoxemia as it allows to
- Deliver a high FiO2 (100% if needed during IPPV)
- Reduce shunt by maintaining flooded or collapsed alveoli open

Others
• Intubation to facilitate procedure (bronchoscopy), bronchial suctioning
Important Pitfalls and Problems Associated
with PPV
Potential detrimental effects associated with PPV
• Heart and circulation
- Reduced venous return and afterload

- Hypotension and reduced cardiac output

• Lungs
- Barotrauma

- Ventilator-induced lung injury

- Air trapping

• Gas exchange
- May increase dead space (compression of capillaries)

- Shunt (e.g., unilateral lung disease - the increase in vascular resistance in the
normal lung associated with PPV tends to redirect blood flow in the abnormal
lung)
Important Effects of PPV on Hemodynamics

Decreased preload
• Positive alveolar pressure  ↑ lung volume  compression of the heart
by the inflated lungs  the intramural pressure of the heart cavities rises
(e.g., ↑ RAP)  venous return decreases  preload is reduced  stroke
volume decreases  cardiac output and blood pressure may drop. This
can be minimized with i.v. fluid, which helps restore adequate venous
return and preload.

• Patients who are very sensitive to change in preload conditions (e.g.,


presence of hypovolemia, tamponade, PE, severe air trapping) are
particularly prone to hypotension when PPV is initiated.
Reduced afterload
• Lung expansion increases extramural pressure (which helps pump blood out of
the thorax) and thereby reduces LV afterload.

• When the cardiac performance is mainly determined by changes in afterload


than in preload conditions (e.g., hypervolemic patient with systolic heart
failure), PPV may be associated with an improved stroke volume. PPV is very
helpful in patients with cardiogenic pulmonary edema, as it helps to reduce
preload (lung congestion) and afterload. As a result stroke volume tends to
increase.
Effects of PPV on Hemodynamics

Generally speaking, the effects of PPV on the cardiac chamber

transmural pressures vary in parallel with:

• Airway pressure (e.g., ↑ airway pressure  ↓ venous return)

• Lung compliance (e.g., ↑ compliance  ↓ venous return)

• Chest wall stiffness (e.g., in the obese patients, a given change in


airway pressure and lung volume
will have more impact on the
hemodynamics, given that the pressure rise around the
heart is going to be higher than in patients with
Marini, Wheeler. Crit Care Med. The Essentials.
compliant chest wall, everything else being equal)
1997.
Alveolar Pressure and Gas Exchange

Dead space

Intensity of the effects


PaO2

Oxygen transport

Alveolar Pressure
Note that as airway pressure increases above a certain level (e.g.,
high PEEP [positive end-expiratory pressure]):
• Oxygen transport start to decline despite the rising PaO2 as cardiac output
starts falling.
• Dead space also tends to increase due to compression of alveolar
capillaries by high alveolar pressure, creating ventilated but poorly perfused
alveolar units.
Other Potentially Adverse Effects of Mechanical
Ventilation

Excessive airway pressure and tidal volume can lead to lung injury
(ventilatorinduced lung injury) and contribute to increased mortality.

Lungs of dogs ventilated for a few The Acute Respiratory Distress


hours with large tidal volume Syndrome Network. N Engl J Med.
demonstrate extensive hemorrhagic 2000;342:1301-1308.
injury.
Other Potentially Adverse Effects of Mechanical
Ventilation
In the setting of obstructive physiology (e.g., asthma and COPD),
adjustment of the tidal volume and rate minute ventilation to
restore a normal pH and PaCO2 can lead to air trapping,
pneumothoraces, and severe hypotension.

Upper Panel: When airway resistances are high, there is for a few
breath more air going in than coming out of the lungs (dynamic
hyperinflation). Subsequently, a new equilibrium is reached.
The amount of air trapped can be estimated in a passive patient
by discontinuing ventilation and collecting the expired volume
(lower panel).

The volume of trapped gas is largely determined by:

1. The severity of airway obstruction


2. The ventilator settings (see advance course for details). Of all
the settings, the imposed minutes ventilation (set rate x VT) and
the most important one.
3. The time left between tidal breath for exhalation is less
important if a low VT and VE are targeted.

Tuxen et al. Am Rev Resp Dis 1987;136:872.


Positive Pressure Ventilation:
The Equation of Motion
In a passive subject, airway pressure represents the entire pressure (P) applied across the respiratory system.

The work required to deliver a tidal breath (Wb) = tidal volume (VT) x airway pressure

The pressure (P) associated with the delivery of a tidal breath is defined by the simplified equation of motion of the
respiratory system (lungs & chest wall):

P = VT/CR+ VT/Ti x RR + PEEP total

P elastic P resistive P elastic


Where CR = compliance of the respiratory system, Ti = inspiratory time and VT/Ti = Flow, RR = resistance of the respiratory
system and PEEP total = the alveolar pressure at the end of expiration = external PEEP + auto (or intrinsic) PEEP, if any. Auto
PEEP = PEEP total – P extrinsic (PEEP dialed in the ventilator) adds to the inspiratory pressure one needs to generate a tidal breath.
Work of Breathing

Work per breath is depicted as a pressure-volume area


Work per breath (Wbreath) = P x tidal volume (VT)
Wmin = wbreath x respiratory rate
WEL = elastic work
Volume

Volume

Volume
WR = resistive
work
VT

Pressure Pressure Pressure


The total work of breathing can be partitioned between an elastic and resistive work. By analogy, the pressure needed to inflate
a balloon through a straw varies; one needs to overcome the resistance of the straw and the elasticity of the balloon.
Intrinsic PEEP and Work of Breathing

When present, intrinsic PEEP contributes to the work of breaking and


can be offset by applying external PEEP.
Volume

VT
VT

Dynamic
FRC Hyperinflation
Pressure
PEEPi

PEEPi = intrinsic or auto PEEP; green triangle = tidal elastic work; red loop = flow resistive work; blue rectangle = work
expended in offsetting intrinsic PEEP (an expiratory driver) during inflation
The Pressure and Work of Breathing can be Entirely
Provided by the Ventilator (Passive Patient)

Ventilator

+ +
₊ + + ₊
Work of Breathing Under Passive Conditions

When the lung is inflated by constant flow, time and volume are linearly related.
Therefore, the monitored airway pressure tracing (Paw) reflects the pressure-
volume work area during inspiration. A pressure-sensing esophageal balloon reflects
the average pressure change in the pleural space and therefore the work of chest
wall expansion.
The Work of Breathing can be Shared Between
the Ventilator and the Patient
The ventilator generates positive pressure within the airway and the
patient’s inspiratory muscles generate negative pressure in the pleural
space.
AC mode
PAW

patient machine

PES
time

Paw = Airway pressure, Pes= esophageal pressure


Relationship Between the Set Pressure Support
Level and the Patient’s Breathing Effort

The changes in Pes


(esophageal
pressure) and in the
diaphragmatic
activity (EMG)
associated with the
increase in the
level of mask
pressure (Pmask =
pressure support)
indicate transfer of
the work of
breathing from the
patient to the
ventilator.
Carrey et al. Chest. 1990;97:150.
Partitioning of the Workload Between the
Ventilator and the Patient

How the work of breathing partitions between the patient and the
ventilator
depends on:
• Mode of ventilation (e.g., in assist control most of the work is usually done by the
ventilator)
• Patient effort and synchrony with the mode of ventilation
• Specific settings of a given mode (e.g., level of pressure in PS and set rate in SIMV)
Common Modes of Ventilation

Volume targeted ventilation (flow controlled, volume cycled)


• AC

Pressure targeted ventilation


• PCV (pressure controlled, time cycled)
• PS

Combination modes
• SIMV with PS and either volume or pressure-targeted mandatory cycles
Pressure and Volume Targeted Ventilation

Pressure and volume targeted ventilation obey the same principles set
by the equation of motion. Pressure and volume targeted ventilation
obey the same principles set by the equation of motion.
In pressure-targeted ventilation: an airway pressure target and
inspiratory time are set, while flow and tidal volume become the
dependent variables.
In volume targeted ventilation (flow-controlled, volume cycled), a
target volume and flow (or inspiratory time in certain ventilator) are
preset and pressure and inspiratory time (or flow in the ventilator where
inspiratory time is preset) become the dependent variables.
The tidal volume is the integral of the flow during inspiration = area
under the curve of the flow time curve during inspiration (see next
slide).
Pressure and Volume Targeted Ventilation

VT

Marini, Wheeler. Crit Care Med. The Essentials. 1997.


Assist-control

Set variables
• Volume, TI or flow rate, frequency, flow profile (constant or decel)
• PEEP and FIO2

Mandatory breaths
• Ventilator delivers preset volume and preset flow rate at a set back-up rate

Spontaneous breaths
• Additional cycles can be triggered by the patient but otherwise are identical to
the mandatory breath.
SIMV
Key set variables
• Targeted volume (or pressure target), flow rate (or inspiratory time, Ti), mandated frequency
• PEEP, FIO2, pressure support

Mandatory breaths
• Ventilator delivers a fixed number of cycles with a preset volume at preset flow rate. Alternatively, a
preset pressure is applied for a specified Ti

Spontaneous breaths
• Unrestricted number, aided by the selected level of pressure support
Peak Alveolar and Transpulmonary Pressures

P(t) = VT/CR+ Flow x RR + PEEP tot

Peak Airway Pressure


+ Alveolar Pressure
Plateau pressure
_ _

meanPaw
Palveolar
+ +
_ + _ + _
Ppleural
Intrinsic PEEP
External PEEP

Ptranspulmonary = Palveolar - Ppleural Pplat = Maximum Palveolar


Transpulmonary pressure is a key determinant of alveolar distension.
Monitoring Pressure in Volume Targeted
Ventilation
Plateau pressure tracks the highest tidal alveolar pressure, a key
determinant of alveolar distension.

Plateau pressure (Pplat) is, however, only a surrogate of peak


alveolar distending pressure (transpulmonary pressure = Pplat –
pleural pressure).
• e.g., in a patient with a low chest wall compliance, a given Pplat is typically
associated with a higher pleural pressure but less alveolar distension (smaller
transpulmonary pressure) than in a patient with a compliant chest wall.

The difference between the Ppeak and Pplat tracks the resistive
pressure, as dictated by the equation of motion. During an
inspiratory pause, flow becomes zero, the resistive pressure is
eliminated and the airway pressure drops from its peak to the
plateau pressure.
Airway Resistance and Respiratory System
Compliance

Under conditions of constant flow, the difference


between peak and plateau airway pressures
drives end-inspiratory flow. The quotient of this
difference and the flow setting gives a measure of
airway resistance at end inspiration.

When airflow is stopped in a passively ventilated


patient by occlusion of the expiratory circuit valve
at end inspiration (plateau pressure) and end
expiration (total PEEP), the pressure needed to
overcome the elastic recoil of the lungs and chest
wall during delivery of the tidal volume is given as
the difference in these values. Dividing the
delivered tidal volume by this difference
quantifies the respiratory system compliance.
Mean Airway Pressure

Although measured in the connecting circuit, mean airway


pressure is a valid measure of the pressure applied across the
lung and chest wall, averaged across both phases of the
ventilatory cycle - but only under passive conditions.

Changes in mean airway pressure are produced by changes


in minute ventilation, PEEP, and I:E ratio.

Mean airway pressures affect pleural pressure and lung


distention.

Therefore, changes in mean airway pressure during passive


inflation may influence:
• Arterial oxygenation
• Cardiac output
Pressure Controlled Ventilation
Key set variables:
• Pressure, TI, and frequency
• PEEP and FIO2

Mandatory breaths
• Ventilator generates a predetermined pressure for a preset time

Spontaneous breaths
• PCV-AC mode: same as mandatory breaths
• PCV-SIMV mode: unsupported or PS

Important caveat
• It is important to understand that in pressure-controlled ventilation the relation between the
set rate and minute ventilation is complex. Above a certain frequency (e.g., when intrinsic
PEEP is created due to a reduced expiratory time), the driving pressure (set PC pressure –
PEEPtotal) starts to drop--and so does the delivered tidal volume.
• A pneumothorax or other adverse change in the mechanics of the respiratory system will not
trigger a high alarm pressure but a low tidal volume alarm instead.
Pressure Support

Pressure = set variable.

Mandatory breaths: none.

Spontaneous breaths
• Ventilator provides a preset pressure assist, which terminates when flow drops to a
specified fraction (typically 25%) of its maximum.
• Patient effort determines size of breath and flow rate.
PCV: Key Parameter to Monitor is VT

What Causes a Decreased


VT During PCV?

Change in mechanics
•  airway resistance:
. e.g., bronchospasm
•  respiratory system compliance .
.e.g, pulmonary edema,
pneumothorax
AutoPEEP 
•  expiratory resistance
•  expiratory time
e.g.,  rate
Inspiratory time 
• e.g.,  rate if I:E ratio constant
Auto-PEEP (Intrinsic PEEP, PEEPi)

Note that AutoPEEP is not equivalent to air trapping. Active expiratory muscle contraction is an often under appreciated
contributor
(left panel) to positive pressure at the end of expiration

Marini, Wheeler. Crit Care Med. The Essentials. 1997.


Suspecting and Measuring AutoPEEP

Suspect AutoPEEP if flow at the


end of expiration does not return
to the zero baseline.

End expiratory pause


Pressure

PEEPe Total PEEP

PEEPi

Time
AutoPEEP is commonly measured by performing a pause at the end of expiration. In a passive patient, flow interruption is associated with
pressure equilibration through the entire system. In such conditions, proximal airway pressure tracks the mean alveolar pressure caused by
dynamic hyperinflation.
Approach to MV

Is MV indicated ? NO

YES

Conservative
NO Contraindication to NIPPV ? treatment and
periodic
reassessment
NO
NIPPV
YES
Success ? Invasive MV
NO
Noninvasive Ventilation

Ventilatory support provided without invasive airway


control
• No tracheostomy
• No ETT
Key Differences Between NIPPV and IPPV

Advantages of NIPPV Disadvantages of NIPPV


Allows the patients to Less airway pressure is
maintain normal
functions tolerated
• Speech
Does not protect against
• Eating aspiration
Helps avoid the risks and No access to airway for
complications related to: suctioning
• Intubation
• Sedation
 Less ventilator-associated
pneumonia
Clinical Use of NIPPV in Intensive Care

Decompensated COPD (Hypercapnic Respiratory Failure)

Cardiogenic pulmonary edema

Hypoxic respiratory failure

Other possible indications


• Weaning (post-extubation)
• Obesity hypoventilation syndrome
• Patients deemed not to be intubated
• Post-surgery
• Asthma

Adapted from: Am J Respir Crit Care Med. 2001;163:283-291.


Contraindications to NIPPV
Cardiac or respiratory arrest
Nonrespiratory organ failure
Severe encephalopathy (e.g., GCS < 10)
Severe upper gastrointestinal bleeding
Hemodynamic instability or unstable cardiac arrhythmia
Facial surgery, trauma, or deformity
Upper airway obstruction
Inability to cooperate/protect the airway
Inability to clear respiratory secretions
High risk for aspiration

Adapted from: Am J Respir Crit Care Med. 2001;163:283-291.


Initiating NIPPV

Initial settings:
• Spontaneous trigger mode with backup rate
• Start with low pressures
- IPAP 8 - 12 cmH2O
- PEEP 3 - 5 cmH2O
• Adjust inspired O2 to keep O2 sat > 90%
• Increase IPAP gradually up to 20 cm H2O (as tolerated) to:
- alleviate dyspnea
- decrease respiratory rate
- increase tidal volume
- establish patient-ventilator synchrony
Success and Failure Criteria for NPPV

Improvements in pH and PCO2 occurring within 2 hours


predict the eventual success of NPPV.

If stabilization or improvement has not been achieved


during this time period, the patient should be considered
an NPPV failure and intubation must be strongly
considered.

Other criteria for a failed NPPV trial include: worsened


encephalopathy or agitation, inability to clear secretions,
inability to tolerate any available mask, hemodynamic
instability, worsened oxygenation.
Modes of ventilation

 Ventilator mode is a set of operating characteristics that controls


how the ventilator functions.

 An operating mode describes the way a ventilator is-


• triggered into inspiration
• cycled into exhalation
• what variables are limited during inspiration
• allowing mandatory or spontaneous breaths or both
Controlled Mode Ventilation
Volume control

 The ventilator delivers a preset TV at a specific R/R and inspiratory


flow rate.

 It is irrespective of patients’ respiratory efforts.


 In between the ventilator delivered breaths the inspiratory valve is
closed so patient doesn’t take additional breaths.
 PIP developed depends on lung compliance and respiratory
passage resistance.
Controlled Mode
Ventilation
Volume controlled CMV
 Indications-
• In initial stage when patients “fighting” or “bucking” with the
ventilator
• Tetanus or other seizure activity
• Crushed chest injury
 Disadvantages-
• Asynchrony
• Barotrauma d/t high PAW & dec. lung compliance
• Haemodynamic disturbances
• V/Q mismatch
• Total dependence on ventilator
Pressure Controlled CMV

 Ventilator gives pressure limited, time cycled breaths thus preset


inspiratory pressure is maintained.

 Decelerating flow pattern.


 Peak airway/alveolar pressure is controlled but TV, minute volume
& alveolar volume depends on lung compliance, airway
resistance, R/R & I:E ratio.
PC- CMV
PC-CMV
Advantages-
 Less PAW, thus chances of barotrauma and hemodynamic
disturbances are less.
 Even distribution of gases in alveoli
 In case of leakage, compensation for loss of ventilation is better as
gaseous flow increases to maintain preset pressure.
Disadvantages-
 Asynchrony
 TV dec. if there is dec. lung compliance or inc. airway resistance,
thus causes hypoventilation and alveolar collapse.
 V/Q mismatch.
ASSIST-CONTROL MODE
Ventilation (A-C Mode)
 Ventilator assists patient’s initiated breath, but if
not triggered, it will deliver preset TV at a preset
respiratory rate (control).
 Mandatory mechanical breaths may be either
patient triggered (assist) or time triggered
(control)
 If R/R > preset rate, ventilator will assist, otherwise it
will control the ventilation.
A-C Mode Ventilation
A-C Mode Ventilation

Advantages-
 Dec. patients work of breathing.
 Better patient ventilator synchrony.
 Less V/Q mismatch.
 Prevents disuse atrophy of diaphragmatic muscle.
Disadvantages-
 Alveolar hyperventilation
 Development of high intrinsic PEEP in obstructed pts.
 Inc. mean airway pressure causes hemodynamic disturbances.
Intermittent Mandatory
Ventilation (IMV)

 Ventilator delivers preset number of time cycled mandatory


breaths & allows patient to breath spontaneously at any tidal
volume in between.
Advantages-
 Lesser sedation
 Lesser V/Q mismatch
 Lesser hemodynamic disturbances
Disadvantage-
 Breath stacking- lung volume and pressure could increase
significantly, causing barotrauma.
IMV
Synchronized Intermittent
Mandatory Ventilation (SIMV)

 Ventilator delivers either assisted breaths to the patient at the


beginning of a spontaneous breath or time triggered mandatory
breaths.
 Synchronization window- time interval just prior to time triggering.
 Breath stacking is avoided as mandatory breaths are synchronized
with spontaneous breaths.
 In between mandatory breaths patient is allowed to take
spontaneous breath at any TV.
SIMV
SIMV
SIMV

 It provides partial ventilatory support

Advantages-
 Maintain respiratory muscle strength and avoid atrophy.
 Reduce V/Q mismatch d/t spontaneous ventilation.
 Decreases mean airway pressure d/t lower PIP & inspiratory time
 Facilitates weaning.
SIMV

Disadvantages-
 Desire to wean too rapidly results in high work of spontaneous
breathing & muscle fatigue & thus weaning failure.
Positive End Expiratory
Pressure (PEEP)

 An airway pressure strategy in ventilation that increases the end


expiratory or baseline airway pressure greater than atmospheric
pressure.
 Used to treat refractory hypoxemia caused by intrapulmonary
shunting.
 Not a stand-alone mode, used in conjugation with other modes.

Indications-
 Refractory hypoxemia d/t intrapulmonary shunting.
 Decreased FRC and lung compliance
Physiology of PEEP

PEEP reinflates collapsed alveoli & maintain alveolar inflation during


exhalation.

PEEP

Increases alveolar distending pressure

Increases FRC by alveolar recruitment

Improves ventilation

 Increases V/Q

 Improves oxygenation

 Decreases work of breathing


PEEP
PEEP

Complications
 Dec. venous return and cardiac output.
 Barotrauma
 Inc. ICP d/t impedance of venous return from
head.
 Alteration of renal function & water imbalance.
Continuous Positive
Airway Pressure (CPAP)
 PEEP applied to airway of patient breathing spontaneously

 Indications are similar to PEEP, to ensure patient must have


adequate lung functions that can sustain eucapnic ventilation.
Mandatory Minute
Ventilation (MMV)

 Similar to IMV mode except that minimum minute volume is set


rather than R/R.
 Ventilator measures spontaneous minute volume, if found less than
preset mandatory minute volume, the difference b/w two is
delivered as mandatory breaths by ventilator at preset flow & TV.
 Suited for patients with variable respiratory drive
Disadvantage-
 Hypoventilation as either minute volume recorded is not necessary
alveolar ventilation.
Pressure Support
Ventilation (PSV)
 Supports spontaneous breathing of the patients.
 Each inspiratory effort is augmented by ventilator at a preset level of
inspiratory pressure.
 Patient triggered, flow cycled and pressure controlled mode.
 Decelerating flow pattern.
 Applies pressure plateau to patient airway during spontaneus br.
 Can be used in conjugation with spontaneous breathing in any
ventilator mode.
PSV

 Commonly applied to SIMV mode during spontaneous ventilation


to facilitate weaning

With SIMV, PS-


 Inc. patient’s spontaneous tidal volume.
 Dec. spontaneous respiratory rate.
 Decreases work of breathing.
 Addition of extrinsic PEEP to PS increases its efficacy.
SIMV (VC) -PS
PSV

Disadvantages-
 Not suitable for patients with central apnea. (hypoventilation)
 Development of high airway pressure. (hemodynamic
distubances)
 Hypoventilation, if inspiratory time is short.
Adaptive Support
Ventilation (ASV)
 Available on Galileo ventilator.
 Patient body weight (deadspace) & percent minute volume are
feed in ventilator.
 Ventilator has pre determined setting of 100ml/kg/min.
 Test breath measures compliance, airway resistance & i. PEEP.
 Ventilator selects and provide the frequency, inspiratory time, I:E &
sets high pressure limit for mandatory and spontaneous breaths.
 May be either time triggered or patient triggered.
Proportional Assist
Ventilation (PAV)

 PAV is a spontaneous breathing mode that offers assistance to the


patient in proportion to the patient’s effort.
 Inspiratory flow, volume & pressure are variable & pressure support
changes according to elastance & airflow resistance & patients
demand (volume or flow).
 PAV is set to overcome 80% of elastance & airflow resistance.
 PAV instantaneously measures the flow and volume being pulled in
by the patient, and automatically calculates the compliance and
resistance of the respiratory system to determine how much
pressure to provide for each breath.
PAV

Flow Assist (FA)-


 Pressure is provided to meet patient’s inspiratory flow demand.
 Dec. inspiratory effort to overcome airflow resistance.
Volume Assist (VA)-
 Pressure is provided meet patient’s volume requirement.
 Dec. inspiratory efforts to overcome systemic elastance.

Indications-
 Spontaneously breathing patient
 Intact respiratory drive
 Intact neuromuscular function
 Generally, a patient considered suitable for pressure support ventilation could
be considered for PAV.
PAV

Advantage-
 The patient ‘drives’ the ventilator
 Better patient ventilator synchrony as pressure vary to augment
flow & demand.

Disadvantage-
 Barotrauma- if elastance & resistance show sudden improvement.
Volume Assured Pressure
Support (VAPS)
 Incorporates inspiratory pressure support ventilation &
conventional volume assisted cycles to provide optimal inspiratory
flow during assisted/controlled ventilation.
 Desired TV & pressure support level are preset.
 Once triggered desired PS level reaches asap & delivered volume
is compared with preset TV.
 If volume delivered = 0r > preset volume, it is PS breath.
 If volume < preset volume, ventilator switches to volume limited,
resulting in longer inspiratory time until preset TV is delivered
Pressure Regulated
Volume Control (PRVC)

 Used to achieve volume support while keeping PIP to lowest level.

 Achieved by altering the peak flow & inspiratory time in response


to changing airway or compliance characteristics.

 At constant flow PIP increases d/t inc. airflow resistance, so


decreasing flow reduces the airflow resistance.

 To compensate for lower flow, inspiratory time is prolonged.


Airway Pressure Release
Ventilation (APRV)

 Similar to CPAP as patient breathes spontaneously.

 Airway pressure is maintained at moderately high level (15-20 cmH2O)


throughout most of respiratory cycle with brief periods of lower
pressure to allow deflation of lungs.

 Inc. pressure ensures alveolar recruitment & oxygenation & brief


deflation allows CO2 elimination without alveolar collapse.

 Indicated as an alternative to conventional volume cycled ventilation


for patients with decreased lung compliance (ARDS), as chances of
barotrauma is less d/t less PAW.
APRV
Inverse Ratio Ventilation
(IRV)
 Used to promote oxygenation esp. in ARDS.
 Normal I:E ratio is 1:1.5 – 1:3, in IRV I:E is 2:1 – 4:1
 Improves oxygenation by
• Reducing intrapulmonary shunting.
• Improving V/Q mismatch.
• Decreasing deadspace ventilation.
• Increasing mean airway pressure.
• Presence of auto PEEP.
Disadvantages-
 Barotrauma d/t inc. mPaw & auto PEEP.
 High rate of transvascular fluid flow. May worsen pulm. oedema
Tracheal Gas Insufflation
(TGI)

 Adjuvant to mechanical ventilation in which O2 enriched gas is


insufflated into trachea to ventilate anatomical dead space
during expiration.

 Decreases PaCO2 at any level of inspiratory minute ventilation.

 Extra flow may cause inc. airway pressure and hyperinflation.


Independent Lung
Ventilation (ILV)

 It is simultaneous separate ventilation of individual lung.


 Separation achieved by double lumen tube and two ventilators-
synchronized or asynchronized.
Indication-
 Severely diseased one lung which can not be treated with
conventional ventilation.
e.g.- unilateral pulmonary contusion, aspiration pneumonia,
bronchopleural fistula, massive unilateral pulmonary embolism etc.
High frequency ventilation
(HFV)

 For all high frequency techniques during which tidal volume


equals or less than anatomical dead space volume and
respiratory frequency between 60 to 3000 breaths / minutes.

They are 3 types:


 HFPPV …..60 to 110 breaths/min
 HFJV…….110 to 600 breaths/min
 HFO……..600 to 3000 breaths/min

Advantages-
Low PAW, less V/Q mismatch, less barotrauma
Ventilator Waveforms:
Basic Interpretation and
Analysis
Outline of this presentation

 Goal:
 To provide an introduction to the concept of
ventilator waveform analysis in an interactive
fashion.
 Content:
 Outline of types of ventilatory waveforms.
 Introduction to respiratory mechanics and the
‘Equation Of Motion’ for the respiratory system
 Development of the concept of ventilator
waveforms
 Illustrations and videos of waveforms to
illustrate their practical applications and
usefulness.
Types of Ventilator Waveforms:
Scalars and Loops
Scalars are waveform representations of pressure, flow or volume on the y axis
vs time on the x axis

flow vs time
scalar

Inspiratory
arm

expiratory
arm

pressure vs time
scalar

volume vs time
scalar
Types of Ventilator Waveforms:
Scalars and Loops
Loops are representations of pressure vs volume or flow vs volume
Expiratory
arm

Pressure Vs volume
loop

volume
pressure
Inspiratory
arm

Flow Vs volume
loop
Expiratory
flow

arm

volume
Understanding the flow-time waveform
• There are two components to the flow-time
waveform
– The inspiratory arm:
• Active in nature
• The character is determined by the ventilatory flow settings.
– The expiratory arm:
• Passive in nature
• The character is determined mainly by elastic recoil of the patients
lungs and airway resistance.
• Also affected by patient respiratory effort (if any)

• There are two commonly used types of flow


patterns available on most ventilators
– The ‘square wave’ or ‘constant flow’ pattern
– The ‘ramp’ (decelerating) type pattern
The ‘square wave’ flow pattern

The inspiratory flow rate


remains constant over Inspiratory
the entire inspiration. arm

flow

The expiratory flow is


passive and is
determined by airways time
resistance and the
elastic recoil of the lungs

Expiratory
Inspiratory time = Tidal volume arm
Flow rate
The ‘decelerating ramp’ flow pattern

The inspiratory flow rate


decelerates as a function
Inspiratory
of time to reach zero flow
arm
at end inspiration

flow

For a given tidal volume,


the inspiratory time is
higher in this type of flow
pattern as compared to time
the square wave pattern

Expiratory
Inspiratory time = Tidal volume arm
Flow rate
Now let us try to understand the
following in the next few slides

•A BASIC VENTILATOR CIRCUIT DIAGRAM


•AIRWAY PRESSURES
•THE EQUATION OF MOTION FOR THE RESPIRATORY
SYSTEM
•THE PRESSURE-TIME WAVEFORM
Understanding the basic
ventilator circuit diagram

ventilator

The ventilator makes up the first part


Essentially the circuit diagram of a
of the circuit. Its pump like action is
mechanically
The patient’s ventilated patientsystem
own respiratory can be ET Tube
depicted simplistically as a piston
broken
Makes up down
the 2 into
nd parttwo
of parts…..
the circuit. airways
These twothat movesare
systems in aconnected
reciprocating
by fashion
The diaphragm is also
during the shown as a cycle.
respiratory
an endotracheal tube which
2nd piston; causing air to be drawn we can
into
consider as an extension
the lungs during contraction.of the
patients airways.

Chest wall Diaphragm


Understanding airway pressures
The respiratory system can be thought of as a mechanical
system consisting of a resistive (airways) and elastic
(lungs and chest wall) element in series

ET Tube
PLungs= + Chest
Flow wall
Resistance + Volume Paw
THUS Airways
aw
(elastic element) Compliance Airway pressure
(resistive element) airways

Airways Lungs + Chest wall


The contribution of the elastic element
(resistive
(lungs element)
+ chest
The contribution depends on (elastic
wall) resistance
of airway element)
pressurethe degreeonofthe
depends lung inflation
rate and
of airflow
and thethe underlying
underlying compliance
resistance of the
(caliber)
lungs
of theand the chest wall
airways
PPL
Pleural pressure

Chest wall

Flow resistance
Volume Diaphragm
compliance

Palv
Alveolar pressure
Understanding basic respiratory mechanics

Thus the equation of motion for the respiratory system ventilator


is

P applied (t) = Pres (t) + Pel (t)E


RET
lungs
tube ET Tube
Raw
Ers airways

Rairways
Echest wall
Thus to move
The total air into
‘elastic’ the lungs
resistance (Eat a given time (t),
rs) offered by the
The total ‘airway’ to the(R
resistance (P) of
the ventilator
respiratory hassystem
to generate
is equala pressure aw
sum applied) Diaphragm
Let us now
in theunderstand
that is sufficient mechanically how the respiratory
ventilated patient systems’
elasticto overcome offered
resistances the pressure
by thegenerated
inherent
is equal elastance
to the sum and
of theresistance
resistancesto airflow
offered
by the elastic (PLung el (t)) Eand airway
and (P
theaw ) resistances
lungs generated within a
determines the pressures (R ET
offeredby the
by theendotracheal
respiratory
chest wall
tube
system
E chest tube)time.
at that
mechanically ventilated
and the patient’s airways ( R airways) system.
wall
Understanding the pressure-time waveform
using a ‘square wave’ flow pattern
Ppeak
pressure

Pres

ventilator
Pplat
Pres
RET tube
time
Pres

Rairways

After this, the pressure rises in a linear fashion


toThe
At
finally
the
pressure-time
beginning
reach Ppeakof waveform
. Again
the inspiratory
at end
is a reflection
inspiration,
cycle, Diaphragm
the
air of
ventilator
flow
theispressures
zero
hasandto the
generate
generated
pressure
a within
pressure
dropsthebyPan
res
amount
to
airways
overcome
equal
during
to the
Pres
each
airway
to reach
phase
resistance.
the
of the
plateau
Note:
pressure
No volume
Pventilatory
plat. The
is delivered
pressure
cycle. atreturns
this time.
to
baseline during passive expiration
Now let’s look at some different pressure-time
waveforms using a ‘square wave’ flow pattern

Paw = Flow Resistance + Volume


Compliance

Scenario # 1
pressure

Ppeak
Normal values:
Pres Ppeak < 40 cm H2O
Pplat < 30 cm H2O
Pres < 10 cm H2O
Pplat
Pres

flow
time

This is a normal pressure-time waveform time


With normal peak pressures ( Ppeak) ;
plateau pressures (Pplat )and
‘Square wave’
airway resistance pressures (Pres) flow pattern
Waveform showing increased airways resistance

Paw = Flow Resistance + Volume + PEEP


Compliance

Scenario # 2
pressure

Ppeak Normal
e.g. ET tube
blockage
Pres

Pplat
Pres

flow
time

The increase in the peak airway pressure is driven time


entirely
This isby
anan
abnormal
increasepressure-time
in the airwayswaveform
resistance
pressure. Note the normal plateau pressure. ‘Square wave’
flow pattern
Waveform showing increased airways resistance

‘Square
wave’ flow
pattern

Ppeak

Pplat

Pres
Waveform showing high airway resistance
due to high flow rates
Paw = Flow Resistance + Volume + PEEP
Compliance
Scenario # 3
pressure

Ppeak Normal
e.g. high flow
Pres rates

Pplat

Pres

time

flow
The increase in the peak airway pressure is driven time
Normal (low)
entirely by abnormal
This is an an increase in the airways
pressure-time resistance
waveform flow rate
pressure caused by excessive flow rates.
‘Square wave’
Note the shortened inspiratory time and high flow flow pattern
Waveform showing decreased lung
compliance
Paw = Flow Resistance + Volume + PEEP
Compliance
Scenario # 4
pressure

Ppeak Normal
e.g. ARDS
Pres

Pplat

Pres

flow
time
The increase in the peak airway pressure is driven
entirely by the decrease in the lung compliance. time
This is an abnormal
Increased airways pressure-time waveform
resistance is often
also a part of this scenario. ‘Square wave’
flow pattern
Waveform showing decreased lung
compliance

‘Square
wave’ flow
pattern

Ppeak

Pplat

Pres
Now lets look at the same pressure-time tracings
using a ‘decelerating ramp’ flow pattern

Normal High Raw:


High
(e.g. asthma)
Normal PIP
PIP

Normal Normal
Pplat Pplat
pressure

High flow: High


High
(Note short
PIP Low CL:
PIP
Inspiratory e.g.
time) ARDS

High
Normal Pplat
Pplat

time
Now let us try to understand the
practical aspects of ventilator
waveform analysis in an
interactive fashion.
Clinical applications of
ventilator waveform analysis
 Ventilator waveforms can be very useful in many
different situations including:
 Diagnosing a ventilator that is ‘alarming’
 Detecting obstructive flow patterns on the ventilator
 Detecting air trapping and dynamic hyperinflation
 Detecting lung overdistention
 Detecting respiratory circuit secretion build-up
 Detecting patient-ventilator interactions
 Dyssynchrony
 Double triggering
 Wasted efforts
 Flow starvation
Some ventilators with waveform displays

Puritan Bennett 840 Puritan Bennett 7200 Dräger Evita XL

Siemens Servo 300A Bear 1000 series Respironics Esprit


Waveform selection on different ventilators

PB 840
Ventilator
Select different
waveforms

Size
adjustment

Time scale

Push to start
waveforms
Waveform selection on different ventilators

Respironics
Espirit
ventilator

Push to select
waveforms
Waveform selection on different ventilators

Switch between
waveforms

Respironics
Espirit
ventilator

Press to
adjust size

Switch between
Loops and scalars
Variables that govern how a ventilator functions and
interacts with the patient
Control variable
‘The Mode of Ventilation’
Pressure, flow, or volume
controlled

Limit Variable
Volume, pressure or flow
can be set to be constant
or reach a maximum

Triggering variable
pressure, flow or volume
sensing that initiates
the vent cycle

Cycle variable
Pressure, volume, flow,
or time that ends the
inspiratory phase
should I be
observing and
analyzing?
LOOK AT THE WAVEFORMS THAT ARE VARYING
BASED ON THE SETTINGS YOU HAVE ORDERED
Mode of ventilation -> useful waveforms
Mode of Independent Dependent Waveforms that will Waveforms that
ventilation variables variables be useful normally
remain
unchanged
Volume Tidal volume, Paw Pressure-time:-> Volume-time
Control/ RR, Flow rate, changes in Pip, Pplat Flow time
Assist- PEEP, I/E ratio Flow-time (expiratory): - (inspiratory)
Control >changes in compliance Flow-volume loop
Pressure-volume loop:->
overdistension, optimal
PEEP
Pressure Paw, Inspiratory Vt, flow Volume-time and flow- Pressure-time
Control time (RR), time: -> changes in Vt and
PEEP and I/E compliance
ratio Pressure-volume loop:->
overdistension, optimal
PEEP

Pressure PS and PEEP Vt,and RR, Volume- time


support/ Flow- time
flow, I/E
CPAP (for Vt and VE)
Ratio

Vt=tidal volume; RR=respiratory rate; Paw=airway pressure; PEEP= positive end expiratory pressure; I/E ratio= inspiratory/expiratory time;

VE= minute ventilation; Pip = Peak inspiratory pressure; Pplat = Plateau pressure
Waveforms to observe during volume
assist control ventilation

 Pressure-time waveform:
 Affected by patient effort and changes in
resistance and compliance
 Flow-time waveform:
 Expiratory flow is not fixed, waveform is dependent
on elastic recoil pressure of respiratory
system/patient effort
 Therefore this scalar is nearly always of interest
Waveforms to observe during pressure
targeted ventilation: PCV

 Pressure-time waveform usually will not change


 Flow-time and volume-time waveform will be affected by
changes in compliance, resistance and the patient’s
respiratory muscle strength (independent variables)
begin riding the
‘waves’ by
looking at a few
ventilator
waveforms!
Basic ventilator waveforms

Mode of ventilation: Assist/control – square


wave flow

 Airway pressures: dependent on lung compliance, tidal


volume and flow (dependent variable)
 Tidal volumes, respiratory rate: ventilator controlled
 Flow pattern: ventilator controlled (square wave pattern)
 Inspiratory time: ventilator controlled
 Waveforms shown: flow-time and pressure-time
Square wave volume assist/control mode

Any abnormalities? : No
PEARL: always look at both inspiratory and expiratory arms
of the flow-time waveform. Make it a habit!
Basic ventilator waveforms

Mode of ventilation: Assist/control – decelerating flow pattern

 Airway pressures: dependent on lung compliance, tidal


volume and flow (dependent variable)
 Tidal volumes, respiratory rate: ventilator controlled
 Flow pattern: ventilator controlled (decelerating wave
pattern)
 Inspiratory time: ventilator controlled
 Waveforms shown: flow-time and pressure-time
Decelerating flow volume assist/control mode

Any abnormalities? : No
PEARL: At similar flow rates, the inspiratory time is shorter (and
peak pressures higher) for the square wave flow as compared to the
decelerating flow pattern.
Basic ventilator waveforms

Mode of ventilation: CPAP + PS

 Airway pressures: patient controlled (indirectly


through control of volume and flow)
 Flow pattern: patient controlled
 Inspiratory time, respiratory rate: patient
controlled
 Waveforms shown: flow-time and volume-time
CPAP with Pressure Support

Any abnormalities?: No
PEARL: notice how each breath differs in flow pattern and
tidal volume.
Basic ventilator waveforms

Mode of ventilation: pressure control ventilation (PCV)

 Airway pressures: ventilator controlled


 Respiratory rate: ventilator controlled
 Tidal Volumes: dependent variable (lung compliance)
 Flow rates: ventilator controlled (decelerating in this instance)
 Waveforms shown: flow-time and volume-time
Pressure Assist/Control – Decelerating Flow

Any abnormalities? : No
PEARL: tidal volumes and flow rates are determined by lung
compliance. Increasing inspiratory time beyond a certain point will
only decrease expiratory time, without any increases in tidal volumes
achieved.
Let us now shift gears and see how waveforms
can help us recognize some common ventilator
related problems!

Common problems
that can be diagnosed
by analyzing
Ventilator waveforms

Patient-ventilator
Abnormal ventilatory Ventilatory circuit related
Interactions
Parameters/lung mechanics problems
E.g. flow starvation,
E.g.. Overdistension, E.g. auto cycling and
Double triggering,
Auto PEEP Secretion build up in the
Wasted efforts
COPD Ventilatory circuit
Active expiration
Now let us learn to recognize
Lung overdistension
and the development of
Auto PEEP

Patient-ventilator
Abnormal ventilatory Ventilatory circuit related
Interactions
Parameters/lung mechanics problems
E.g. flow starvation,
E.g.. Overdistension, E.g. auto cycling and
Double triggering,
Auto PEEP Secretion build up in the
Wasted efforts
COPD Ventilatory circuit
Active expiration
Let us briefly revisit the flow-time
waveform

 As previously noted, the flow-time waveform has both an inspiratory


and an expiratory arm.

 The expiratory arm is passive in nature and its character is


determined by:
 the elastic recoil of the lungs
 the airways resistance
 and any respiratory muscle effort made by the patient during expiration
(due to patient-ventilator interaction/dys=synchrony)

 The expiratory arm can be thought of in some ways as passive


bedside spirometry.

 It should always be looked at as part of any waveform analysis and


can be diagnostic of various conditions like COPD, auto-PEEP,
wasted efforts, overdistention etc.
RECOGNIZING
LUNG
OVERDISTENSION
Recognizing lung overdistension
Suspect this when:

There are high peak and plateau


Pressures…

Accompanied by high expiratory


Flow rates

The pressure-time waveform


Shows an abrupt increase in
Pressure.

PEARL: Think of right mainstem intubation,


low lung compliance (e.g. ARDS),
excessive tidal volumes etc
The pressure-volume loop can tell us a lot
about lung physiology!
Compliance (C)
is markedly reduced in the
injured lung on the right as
compared
Normal to the normal lung
lung on the left

Upper inflection point (UIP)


above this pressure,
additional alveolar recruitment
requires disproportionate
increases
ARDS in applied airway pressure

Lower inflection point (LIP)


Can be thought of as the
minimum
baseline pressure (PEEP)
needed for optimal
alveolar recruitment
Observe a pressure-volume loop illustrating
the concept of overdistension

Peak
Inspiratory
pressure

Upper
Inflection
point

Lower
Inflection
point
Lung overdistension based
on pressure-volume loops
Recognizing
Auto-PEEP
Detecting Auto-PEEP

Recognize
Auto-PEEP
when

Expiratory flow continues


and fails to return to
the baseline prior to the new
inspiratory cycle
The development of auto- PEEP over several
breaths in a simulation

Notice how the expiratory flow fails


to return to the baseline causing
progressive air trapping

Also notice how the progressive


air trapping causes a gradual
increase in airway pressures
due to decreasing compliance
Development of auto-
PEEP
Notice how the expiratory
flow fails to return to
the baseline causing
progressive air trapping

Click here to watch video

Also notice how the


progressive air trapping
causes a gradual
increase in airway
pressures because of
decreasing compliance
Understanding how flow rates affect I/E ratios
and the development of auto PEEP

Decreasing the flow rate

Increase the inspiratory time


and consequently decrease the
expiratory time
(decreased I/E ratio)

Thus allowing only incomplete emptying


of the lung and the development
of air trapping and auto-PEEP

Lluis Blanch MD, PhD et al: Respiratory Care Jan 2005 Vol 50 No 1
Understanding how inspiratory time affect I/E
ratios and the development of auto-PEEP

 In a similar fashion, an increase in inspiratory time


can also cause a decrease in the I: E ratio and
favor the development of auto-PEEP by not
allowing enough time for complete lung emptying
between breaths.

 Watch in the next video how auto-PEEP develops in


a patient on Pressure control ventilation at a RR of
20, just by increasing the inspiratory time from 0.85
sec to 1.0 sec (no auto-PEEP develops) and then to
1.5 sec (development of auto PEEP)
Ventilator settings before and after the
development of auto-PEEP
Mode of ventilation: PCV ( pressure control
ventilation)
 Waveforms depicted: flow-time and pressure-time
 Pressure support: 15cm/H2O with PEEP of 5 cm/H2O
 Respiratory Initial
Ventilator rate: 20 bpm Subsequently Final
settings settings settings
Inspiratory 0.85 sec 1.0 sec 1.5 sec
time
Expiratory 2.15 sec 2.0 sec 1.5 sec
time
I : E ratio 1 : 2.5 1: 2 1: 1
Auto PEEP No No Yes
Development of auto-PEEP with
inadequate expiratory time

Click here to watch video


Recognizing Expiratory Flow
Limitation (e.g. COPD,
asthma)
Recognizing prolonged expiration (air trapping)

Recognize
Airway obstruction
when

Expiratory flow quickly tapers off


and then enters a prolonged
low-flow state without returning to
baseline (auto- PEEP)

This is classic for the flow


limitation and decreased lung
elastance characteristic of COPD
or status asthmaticus
Let us now move forward and
Learn about diagnosing
patient-ventilator Interactions
by analyzing ventilator
waveforms

Patient-ventilator
Abnormal ventilatory Ventilatory circuit related
Interactions
Parameters/lung mechanics problems
E.g. flow starvation,
E.g.. Overdistension, E.g. auto cycling and
Double triggering,
Auto PEEP secretion build up in the
Wasted efforts
COPD Ventilatory circuit
Active expiration
Recognizing:
Wasted efforts
Double triggering
Flow starvation
Active expiration
Recognizing ineffective/wasted patient effort

Patient inspiratory effort


fails to trigger vent cycle
resulting in a wasted effort

Results in fatigue, tachycardia,


Increased metabolic needs,
Fever etc
Recognizing double triggering
High peak airway
pressures and
double the inspiratory
volume

Continued patient inspiratory efforts


through the end of a delivered
breath cause the ventilator to cycle again
and deliver a 2nd breath on top of the
first breath that has still not been completely
exhaled.
This results in high lung volumes and
pressures.

Consider switching mode,


increasing sedation, or
neuromuscular paralysis
as appropriate
Another example of double triggering
Recognizing flow starvation

Look at the pressure-time


waveform

If you see this kind of


scooping or distortion instead
of a smooth rise in the
pressure curve….

Diagnose flow starvation


in the setting of patient
discomfort, fatigue,
dyspnea etc on the vent
Recognizing active expiration

Look at the flow-time


& pressure-time
Waveform

In this situation, the patient is


making active expiratory efforts
during the inspiratory
phase of the ventilator delivered
breath cycle

Notice how the expiratory


flow and the pressure rise
dramatically as a result
of the opposing forces at
work
Lastly let us learn to recognize
Ventilatory circuit related
problems by analyzing
ventilatory waveforms

Abnormal ventilatory Patient-ventilator


Ventilatory circuit related
Parameters/lung mechanics Interactions
problems
E.g.. Overdistension, E.g. flow starvation,
E.g. auto cycling and
Auto PEEP Double triggering,
secretion build up in the
COPD Wasted efforts
Ventilatory circuit
Secretions
&
Ventilator Auto-
Cycling
Recognizing airway or tubing secretions

Flow volume loop


Normal flow-volume showing a ‘saw tooth’
loop pattern typical of
retained secretions
Characteristic scalars due to secretion
build up in the tubing circuit
Recognizing ventilator auto-cycling

 Think about auto-cycling when the respiratory rate


increases suddenly without any patient input and if the
exhaled tidal volume and minute ventilation suddenly
decrease.
 Typically occurs because of a leak anywhere in the
system starting from the ventilator right up to the patients
lungs
 e.g. leaks in the circuit, ET tube cuff leak, lungs
(pneumothorax)
 May also result from condensate in the circuit
 The exhaled tidal volume will be lower than the set
parameters and this may set off a ventilator alarm for
low exhaled tidal volume, low minute ventilation, circuit
disconnect or rapid respiratory rate.
THANK YOU