Ventilator Waveforms:
Interpretation
Albert L. Rafanan, MD, FPCCP
Pulmonary, Critical Care and Sleep Medicine
Chong Hua Hospital, Cebu City
Types of Waveforms
• Scalars are waveform representations of pressure,
flow or volume on the y axis vs time on the x axis
• Loops are representations of pressure vs
volume or flow vs volume
Scalar Waveforms
Loop
Common problems
that can be diagnosed
by analyzing
Ventilator waveforms
Abnormal ventilatory Patient-ventilator
Ventilatory circuit related
Parameters/ Interactions
problems
lung mechanics E.g. flow starvation,
E.g. auto cycling and
E.g.. Overdistension, Double triggering,
Secretion build up in the
Auto PEEP Wasted efforts
Ventilatory circuit
COPD Active expiration
Lung Mechanics
• Use Scalar
• Pressure Time Waveform with a square wave
flow pattern
Understanding the basic ventilator circuit diagram
ventilator
TheEssentially
ventilatorthe circuitupdiagram
makes the firstofpart
a
mechanically
of the
The circuit.ventilated
patient’s Its pump
own patient can isbe
like action
respiratory system ET Tube
broken
depicted
makes down 2ndinto
parttwo
simplistically
up the parts…..
ofasthe
a piston
circuit. airways
These
that two
Themoves systems are connected
in a reciprocating
diaphragm as aby
is also shownfashion
anpiston;
2nd endotracheal
duringcausing tube
air towhich
the respiratory we can
be cycle.
drawn into
consider as an extension
the lungs during contraction. of the
patient’s airways.
Chest wall Diaphragm
Understanding airway pressures
The respiratory system can be thought of as a mechanical
system consisting of resistive (airways +ET tube) and elastic
(lungs and chest wall) elements in series
THUS Paw = Flow X Resistance + Volume x 1/Compliance
Paw
ET Tube
Airway pressure
airways
ET tube + Airways Lungs + Chest wall
Airways
Lungs + element)
(resistive +Chest
ET tube
wall (elastic element)
(resistive
(elastic element)
PPL
Resistive Pleural pressure
The elasticpressure
pressurevaries
varieswith
withairflow
volume and
and the diameter of ETT and airways.
stiffness of lungs and chest wall. Chest wall
Diaphragm
Flow resistance
Pel = Volume x 1/Compliance Palv
Alveolar pressure
Understanding basic respiratory mechanics
Thus the equation of motion for the respiratory system Ventilator
is
Paw (t) = Pres (t) + Pel (t)E
RET
lungs
tube ET Tube
Raw
Ers airways
Rairways
Echest wall
The total ‘elastic’ resistance (Ers) offered by the
the(R aw)systems’
Let us now Theunderstand how resistance
total ‘airway’ the respiratory
Thus respiratory
to move airsystem
into theislungs
equalattoany sum
given of
time (t),
inherent
in the elastance
mechanically and ventilated
resistance patient
to airflow Diaphragm
theelastic resistances
ventilator offered by
has to generate the
sufficient
determines thesum
is equal to the pressures
of the generated
resistanceswithin a
offered
pressure (PawLung(t)) E
to and
overcome
lungs thethe combined
bymechanically
the endotrachealventilated
tube (Rsystem.
ET tube)
elastic (Pel (t))chest wall E chest(Pwall
and resistance res(t)) properties
and the patient’s airways ( R airways)
of the respiratory system
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
to finally reach Ppeak. Again at end inspiration,
The
At pressure-time
the beginning waveform is a reflection
of the inspiratory cycle, Diaphragm
air flow is zero and the pressure drops by an
theofventilator
the pressures
has togenerated
generate within the P
a pressure
amount equal to Pres to reach the plateau res
airways duringthe
to overcome each phase
airway of the
resistance.
pressure Pplat. The pressure returns to
ventilatory
Note: No volume cycle. at this time.
is delivered
baseline during passive expiration.
Pressure-time waveforms using a ‘square wave’ flow pattern
Paw(peak) = Flow x Resistance + Volume x 1/ Compliance
Scenario # 1
Paw(peak)
pressure
Pres
Pplat
Pres
time
flow
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 high airways resistance
Paw(peak) = Flow x Resistance + Volume x 1/ Compliance + PEEP
Scenario # 2
pressure
Ppeak Normal
Pres e.g. ET tube
blockage
Pplat
Pres
time
flow
The increase in the peak airway pressure is driven time
entirely
This is anbyabnormal
an increase in the airways
pressure-time resistance
waveform
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 inspiratory flow rates
Paw(peak) = Flow x Resistance + Volume x 1/compliance + PEEP
Scenario # 3
Paw(peak)
pressure
Normal
Pres e.g. high flow
rates
Pplat
Pres
time
flow
Normal (low) time
The increase in the peak airway pressure is caused flow rate
This inspiratory
by high is an abnormal
flowpressure-time waveform
rate and airways resistance.
Note the shortened inspiratory time and high flow ‘Square wave’
flow pattern
Waveform showing decreased lung compliance
Paw(peak) = Flow x Resistance + Volume x 1/ Compliance + PEEP
Scenario # 4
Paw(peak)
pressure
Normal
Pres
e.g. ARDS
Pplat
Pres
time
flow
The increase in the peak airway pressure is driven
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
Common problems
that can be diagnosed
by analyzing
Ventilator waveforms
Abnormal ventilatory Patient-ventilator
Ventilatory circuit related
Parameters/ Interactions
problems
lung mechanics E.g. flow starvation,
E.g. auto cycling and
E.g.. Overdistension, Double triggering,
Secretion build up in the
Auto PEEP Wasted efforts
Ventilatory circuit
COPD Active expiration
Recognizing Lung Overdistension
Flow-time waveform
• Flow-time waveform has both an inspiratory and an expiratory
arm.
• The shape of the expiratory arm 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)
• 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
Suspect this when:
There are high peak and plateau
Pressures…
Accompanied by high expiratory
flow rates
PEARL: Think of
low lung compliance (e.g. ARDS),
excessive tidal volumes,
right mainstem intubation etc
The Stress Index
• In AC volume ventilation using a
constant flow waveform observe the
pressure time scalar.
flow
• Normal, linear change in airway
pressure Stress index =1
Paw
• Upward concavity indicates decreased
compliance and lung overdistension
Stress index > 1
• Downward concavity indicates
increased compliance and potential
alveolar recruitment
Stress index < 1
Note: Patient effort must be absent time
The Stress Index
Pressure-volume loop
Compliance (C)
is markedly reduced in the
injured lung on the right as
compared to the normal lung
Normal on the left
lung
Upper inflection point (UIP)
above this pressure,
additional alveolar recruitment
requires disproportionate
increases in applied
ARDS airway pressure
Lower inflection point (LIP)
Can be thought of as the
minimum baseline
pressure (PEEP)
needed for optimal
alveolar recruitment
Overdistension
Peak
inspiratory
pressure
Upper
inflection
point
Note: During normal ventilation the LIP cannot be assessed due to the effect of
the inspiratory flow which shifts the curve to the right
Recognizing Auto-PEEP
Dynamic Hyperinflation (Gas Trapping)
• Dynamic hyperexpansion, defined as premature
termination of exhalation, often occurs when respiratory
rate, inspiratory time, or both have been increased.
• By not permitting exhalation to finish, an increase in mean
airway pressure results.
• Gas trapping may occur leading to an elevation in PCO2.
• Careful attention must be paid to dynamic hyperexpansion
in patients with obstructive lung disease whose long time
constants and slow emptying can result in progressive air
trapping, hypercarbia, and eventually decreased cardiac
output.
Expiratory flow continues and fails to return to the
baseline prior to the new inspiratory cycle
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 indicating
air trapping (AutoPEEP)
Also notice how air trapping causes
an increase in airway pressure
due to increasing end expiratory
pressure and end inspiratory
lung volume.
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 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.
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
Common problems
that can be diagnosed
by analyzing
Ventilator waveforms
Abnormal ventilatory Patient-ventilator
Ventilatory circuit related
Parameters/ Interactions
problems
lung mechanics E.g. flow starvation,
E.g. auto cycling and
E.g.. Overdistension, Double triggering,
Secretion build up in the
Auto PEEP Wasted efforts
Ventilatory circuit
COPD Active expiration
PATIENT-VENTILATOR INTERACTIONS
Wasted efforts
Double triggering
Flow starvation
Active expiration
Ventilator Dyssynchrony: Inaccurate Sensing
of Patient’s Effort
• Many modern ventilators sense patient effort
– by detecting decreases in airway pressure or
– flow between the inspiratory and expiratory limbs of the circuit.
• Inadequate sensing of patient effort leads to tachypnea, increased
work of breathing, ventilator dyssynchrony, and patient discomfort.
• Flow triggering is often used in children, as it is very sensitive to
patients with minimal respiratory effort and small endotracheal
tubes.
• Dyssynchrony also occurs when an air leak leads to loss of PEEP,
resulting in excessive ventilator triggering (auto cycling).
• The unstable pressure baseline that occurs due to leak may be
misinterpreted as patient effort by the ventilator.
Recognizing ineffective/wasted patient effort
Patient inspiratory effort
fails to trigger vent
resulting in a wasted effort
Results in fatigue, tachycardia,
increased metabolic needs,
fever etc
Causes: High AutoPEEP,
respiratory muscle weakness,
inappropriate sensitivity settings
Recognizing double triggering
High peak airway
pressures and
double the inspiratory
volume
Continued patient inspiratory effort
through the end of a delivered
breath causes the ventilator to trigger again
and deliver a 2nd breath immediately after
the first breath.
This results in high lung volumes and pressures.
Causes: patient flow or volume demand exceeds
ventilator settings
Consider: Increasing tidal volume, switching
modes i.e. pressure support, increasing sedation
or neuromuscular paralysis as appropriate
Ventilator Dyssynchrony: Inadequate Ventilatory
Support
• Inadequate ventilatory support occurs when patient effort is not
satiated by the inspiratory flow of the mechanical breath.
• As a result, patients attempt to initiate breaths during a mechanical
breath.
• This phenomenon is seen as a reduction of airway pressure, seen as
a decrease in airway pressure tracing during inspiration (flow
dyssynchrony).
• In volume-limited ventilation a reduction of the inspiratory pressure
as a result of dyssynchronous patient effort can translate into a
higher PIP.
• Titration of flow rate, decreasing inspiratory time, or changing the
mode of ventilation can help meet a patient’s inspiratory demand.
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
Notice the high and variable
expiratory flow rates due to
varying expiratory muscle effort
The patient’s active expiratory efforts
during the inspiratory
phase causes a pressure spike.
PEARL: This is a high drive state where increased sedation/paralysis and mode
change may be appropriate for lung protection.
Common problems
that can be diagnosed
by analyzing
Ventilator waveforms
Abnormal ventilatory Patient-ventilator
Ventilatory circuit related
Parameters/ Interactions
problems
lung mechanics E.g. flow starvation,
E.g. auto cycling and
E.g.. Overdistension, Double triggering,
Secretion build up in the
Auto PEEP Wasted efforts
Ventilatory circuit
COPD Active expiration
Recognizing
Airway 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.
Take home points
• Ventilator waveform analysis is an integral
component in the management of a mechanically
ventilated patient.
• Develop a habit of looking at the right waveform for
the given mode of patient ventilation.
• Always look at the inspiratory and expiratory
components of the flow-time waveform.
• Don’t hesitate to change the scale or speed of the
waveform to aid in your interpretation.
Thank You
Where is the plateau pressure?
2. Which of the
following
waveforms
indicate an
increased
resistance and a
decreased
compliance?
Waveform showing decreased lung compliance
‘Square
wave’ flow
pattern
Ppeak
Pplat
Pres
3. What is the best Stress Index?
This is on AC volume
ventilation using a constant Note: Patient effort must be absent
flow waveform. The graph is a
pressure time scalar.
Paw
time
4. Which waveform shows autopeep?
5. What is shown by the Red Arrow
A. Auto Peep
B. Retained
Secretions
C. Ineffective
Patient Effort
D. Double
Triggering
