BASIC PRINCIPLES OF MECHANICAL

VENTILATION ANDVENTILATOR
GRAPHICS

BASIC PRINCIPLES OF MECHANICAL

VENTILATION
Regardless of the disease states when a patient
fails to ventilate or oxygenate adequately the
problem lies in 1 of 6 pathophysiological factors
1. Increased airway resistance
2. Change in lung compliance
3. Hypoventilation
4. V/Q mismatch
5. Intrapulmonary shunting
6. Diffusion defects

AIRWAY RESISTANCE
Normal airway resistance in term newborn is 20-

40cm H2O/l/sec
Normal airway resistance in adults is 0.6-cm of

1.
2.
3.

H2O /l/sec
Resistance increases by following
Inside the airway retained secretions
In the wall swelling or neoplasm
Outside the wall eg. tumor
Simplified Poiseuilles Law P=V/ r4
P= driving force V=airflow , r=radius of airway

CONDITIONS LEADING TO AIRWAY RESISTANCE

Emphysema
Asthma
Bronchiectasis
Postintubation obstruction
Foreign body
Endotracheal tube (small size and long)
Condensation in vent circuit
ALTB
Bronchiolitis
Epiglottitis

AIRWAY RESISTANCE AND WORK OF

BREATHING

Airway resistance ( Raw) is

P/ V
P=peak airway pressure-plateau pressure
V=flow
Increase in airway resistance means increase

in work of breathing (i.e. pressure change)

Hypoventilation may result if patient is unable
to overcome the resistance by increasing the
work of breathing
It leads to ventilatory and oxgenation failure

VENTILATORY FAILURE is failure of lungs to

eliminate CO2
OXGENATION FAILURE is failure of lung and
heart to provide adequate oxygen for
metabolic needs

LUNG COMPLIANCE
Compliance is lung expansion (volume change) per unit

pressure change(work of breathing) V/ P

Abnormal high or low compliance impairs the patient ability to
maintain effective gas exchange
STATIC COMPLIANCE is measured when there is no
airflow(using plateau pressure PEEP
STATIC COMPLIANCE = tidal volume /plateau pressure- PEEP
DYNAMIC COMPLIANCE is measured when airflow is
present(using the peak airway pressure- PEEP)
DYNAMIC COMPLIANCE = tidal volume / peak airway pressurePEEP
Normal range of compliance in newborn is 1.5-2 ml/cmH2O/kg
Normal range of compliance in adults dynamic= 30-40
ml/cmH2O
Normal range of compliance in adults static= 40-60 ml/cmH2O

LUNG COMPLIANCE CONT-

Static compliance reflects the elastic

properties (elastic resistance) of lung and

chest wall
Dynamic compliance reflects the airway
(nonelastic)resistance and the elastic
properties (elastic resistance) of lung and
chest wall
Conditions causing change in static
compliance invoke similar changes in dynamic
compliance
Where airway resistance is the only
abnormality dynamic compliance change
independently

CLINICAL CONDITIONS THAT DECREASE THE

COMPLIANCE
TYPE OF COMPLIANC
1. STATIC

1. DYNAMIC

1.
2.
3.
4.
5.

CONDITIONS
ATELECTASIS
ARDS
Pneumothorax
Obesity
Retained secretions

1. Bronchospasm
2. Kinking of ET tube
3. Airway obstruction

HIGH COMPLIANCE
Emphysema
Surfactant therapy

VENTILATORY FAILURE
5 mechanisms lead to ventilatory failure
1. Hypoventilation
2. Persistent ventilation perfusion mismatch
3. Persistent intrapulmonary shunting
4. Diffusion defect
5. Reduction in PIO2 i.e. inspired oxygen

tension

HYPOVENTILATION
Caused by depression in CNS
Neuromuscular disease
Airway obstruction
In a clinical setting hypoventilation is

characterised by a reductionof alveolar

ventilation and increase in arterial CO2
tension

VENTIATION PERFUSION MISMATCH

Disease process which causes obstruction or

atelectasis result in less oxygen being available

leading to low V/Q
Pulmonary embolism is an example that decreases
pulmonary perfusion and high V/Q
T/T in mechanical ventilation include increasing
rate , tidal volume , FiO2
T/t directing towards removing
obstruction,recruiting atelectatic zones and
preventing closure

INTRAPULMONARY SHUNTING
Causes refractory hypoxia
normal shunt is less than 10%
10-20%mild shunt
20-30% significant shunt
>30% critical and severe shunt
eg pneumonia and ARDS
Classic Qs/Qt=( CcO2-CaO2)/(CcO2-CvO2)

DIFFUSION DEFECT
TYPE
1. Decrease in pressure

CLINICAL CONDITIONS
1. High altitude, fire

2. Thickening of A-C

2. Pulmonary edema and

3. Decrease surface

3. Emphysema ,

4. Insufficient time of

4. tachycardia

gradient

membrane

areaof A-C membrane

diffusion

combustion

retained secretions
pulmonary fibrosis

Purpose of Graphics
Graphics are waveforms that reflect the patient-

ventilator system and their interaction.

Purpose of monitoring graphics includes:

Allows user to interpret, evaluate, and troubleshoot
the ventilator and the patients response to
ventilator.
Monitors the patients disease status (C and Raw).
Assesses patients response to therapy.
Monitors ventilator function
Allows fine tuning of ventilator to decrease WOB,
optimize ventilation, and maximize patient comfort.

Types of Waveforms
Scalars: plot pressure/volume/flow against

timetime is the x axis

Loops: plot pressure/volume/flow against
each otherthere 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.

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
Pressure Modes

Volume

Volume

Flow

Flow

Pressur
e

Pressur
e

Volume Modes

Volume Control/ SIMV (Vol. Control)

Pressure Control/
PRVC
SIMV (PRVC)
SIMV (Press. Control)

Pressure Support/
Volume Support

Pressure/Time Scalar
In Volume modes,

the shape will be

an exponential
rise or an
accelerating ramp
for mandatory
breaths.

In Pressure modes, the

shape will be
rectangular or square.
This means that
pressure remains
constant throughout
the breath cycle.

In Volume modes, adding an inspiratory pause may improve distribution of ven

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

Pressure/Time Scalar

15
5

No patient effort

PEEP

Patient effort

The baseline for the pressure waveform increases when PEEP is

added.
There will be a negative deflection just before the waveform with
patient triggered breaths.

+5

Pressure/Time Scalar
1

Inspiratory pause
2

A
B

= MAP

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/Time Scalar
Increased Airway
A.Resistance
PIP

B.

Decreased
Compliance
PIP
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.

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 doesnt 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 Volume modes, the

shape of the waveform

will be square or
rectangular.
This means that flow
remains constant
throughout the breath
cycle.

In Pressure modes,

(PC, PS, PRVC, VS)

the shape of the
waveform will have
a decelerating
ramp flow pattern.

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

Pressure

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
doesnt return
to baseline

Start of next breath

If expiratory flow doesnt return to baseline before the next breath starts,
theres auto-PEEP (air trapping) present , e.g. emphysema.

Flow/Time Scalar
Bronchodilator Response
Pre-Bronchodilator

Longer
E-time

Post-Bronchodilator

Shorter
E-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.

Types of Waveforms
Pressure Modes

Volume

Volume

Flow

Flow

Pressur
e

Pressur
e

Volume Modes

Volume Control/ SIMV (Vol. control)

Pressure Control/
Pressure Support/
PRVC
Volume Support
SIMV (PRVC)
SIMVinspiratory
(Press. control)
In Pressure Limited, Time-cycled (control) modes,
flow should return to

baseline.

Types of Waveforms

Notice the area of no flow indicated by the red line. This is known as a zeroflow state.

Pressure/Volume Loops

500

250

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 theres 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.

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
Dynamic
Compliance
(Cdyn)

B
B = Exp.
Resistance/
Elastic WOB

ion
t
ira
p
ex

500

A=
Inspiratory
Resistance/
Resistive
WOB

ion
t
ir a
p
ins

250

15

30

The top part of the P/V loop represents Dynamic compliance (Cdyn).
Cdyn = volume/pressure

Pressure/Volume Loops

Overdistention
beaking

500

250

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

500

re
.
p
ex

ce
n
ta
s
i
s

te
s
y
h

250

s
i
s
re

in
5

15

es
r
.
sp

ce
n
a
ist

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 Compliance

Decreased
Compliance

500

500

250

250

15

Example:
Emphysema,

30

15

30

Example: ARDS, CHF,

Atelectasis

Pressure/Volume Loops

A Leak

500

250

15

30

The expiratory portion of the loop doesnt return to baseline. This indicates a le

Pressure/Volume Loops

Inflection Points

500

250

15

Lower
Inflection
Point

30

The lower inflection point represents the point of alveolar opening

(recruitment).
Some lung protection strategies for treating ARDS, suggest setting PEEP just

Point of upper inflection

C lt changed later during
(Ipu)

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
-20

-40

-60

400

600

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
whats set on the ventilator.
The shape of the exp flow curve represents
passive exhalationits long and more drawn out
in patients with less recoil.
Can be used to determine the PIF, PEF, and Vt

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
60

40

20

Start of
Inspiration

Start of
Expiration

0
200

400

600

-20

-40

-60

PEF

Flow/Volume Loops

The shape of the inspiratory curve will match the flow setting on the
ventilator.

DIFFERENT FLOW VOLUME LOOPS

A, normal loop
B ski-slop observerved in exp.

Flow limitation
C Extrathoracic airway
obstruction with inspiratory
and expiratory air flow
limitation seen in subglotic
stenosis and narrow
endotracheal tube
D Intrathoracic inspiratory
airflow limitationas seen with
babies with intraluminal
obstruction
E unstable airway eg
tracheomalacia
F Erratic airflow in secretions

Flow/Volume Loops

A Leak

60

= Normal
40

20

0
200

400

600

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

Flow/Volume Loops

Airway Obstruction

scooping

Reduced
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.

Air Trapping (auto-PEEP)

Causes:
Insufficient expiratory time
Early collapse of unstable alveoli/airways during exhalation

How to Identify it on the graphics

Pressure wave: while performing an expiratory hold, the

waveform rises above baseline.

Flow wave: the expiratory flow doesnt return to baseline
before the next breath begins.
Volume wave: the expiratory portion doesnt return to baseline.
Flow/Volume Loop: the loop doesnt meet at the baseline
Pressure/Volume Loop: the loop doesnt meet at the baseline

Airway Resistance
Changes
Causes:
Bronchospasm
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 .

Compliance Changes
Decreased compliance
Causes

Increased compliance
Causes

Emphysema
Surfactant Therapy

ARDS
Atelectasis
Abdominal distension
CHF
Consolidation
Fibrosis
Hyperinflation
Pneumothorax
Pleural effusion

How to Identify it on the

graphics

Pressure wave: PIP and

plateau both increase
Pressure/Volume loop: lays
more horizontal

How to Identify it on the

graphics

Pressure wave: PIP and

plateau both decrease
Pressure/Volume loop:
Stands more vertical

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 to ID it
Pressure wave: Decreased PIP
Volume wave: Expiratory side of wave doesnt return to
baseline
Flow wave: PEF decreased
Pressure/Volume loop: exp side doesnt return to the baseline
Flow/Volume loop: exp side doesnt return to baseline

How 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 ID 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
either Insp/Exp.

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

Flow Starvation

The inspiratory portion of the pressure wave shows a scooping or dip, due
to inadequate flow.

Asynchrony

F/V Loop

P/V Loop

Rise Time &

Inspiratory Cycle Off %

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 patients 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 patients inspiratory
demands. If this occurs, you will need to decrease the rise
time to open the valve faster.

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

pressure

flow

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

Inspiratory Cycle Off

100% of Patients
Peak Inspiratory
Flow

100%

Flow

75%
50%
30%

In the above example, the machine is set to cycle inspiration off at 30% of
the patients peak inspiratory flow.

Inspiratory Cycle Off

A

Exhalation
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.

Sources:
Rapid Interpretation of Ventilator Waveforms

Ventilator Waveform Analysis

Susan Pearson
Golden Moments in Mechanical Ventilation
Maquet, inc.
Servo-I Graphics Maquet, inc.
text book of physiology- Ganong
David W Chang clinical application of mechanical
ventilation
Pulmonary function and graphics -Goldsmith

Thank You!