Ventilator Graphics

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By: wudawei (17 month(s) ago)

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By: drjoneshk (46 month(s) ago)

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By: mercador (46 month(s) ago)

Thanks for taking the time to make this presentation. its good for reinforcing what we think we know!

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By: doceaswar (50 month(s) ago)

great presentation

Presentation Transcript

Slide 2: 

NEONATAL PULMONARY GRAPHICS ART OF VENTILATION IN TO SCIENCE OF VENTILATION Dr Vishram Buche Director, NICU Central India’s CHILD hospital & Research institute, NAGPUR

Slide 3: 

How to identify different WAVES and LOOPS ? and differentiate between normal and abnormal ? How it helps to identify the mode of Vent ? How it helps to adjust vent settings / vent circuits ? How it helps to manage disease pattern ? I. Progression 2. Responding to drugs.. 3. Deterioration How it helps to identify / quantify the problem? still many more……..

Measured Parameters…. : 

Measured Parameters…. Flow Pressure Time Calculated Parameters ….. Volume (as an integration of flow) Compliance Resistance Work of Breathing Auto-PEEP

Measurement of Flow……… : 

Measurement of Flow……… How it is Measured?....... 1 Pressure Differential Pneumotachometer 2 Hot Wire Anemometer Where it is measured? …. 1. At ETT 2. Inside the ventilator

Measurement of Pressure…… : 

Measurement of Pressure…… Where is it Measured? At ETT In Esophagus Inside Ventilator

Slide 7: 

A. Trigger ……. What causes the breath to begin? B. Limit …… What regulates gas flow during the breath? C. Cycle ……. What causes the breath to end? Basics phase variables…………..

Slide 8: 

The Pulmonary graphics display in two formats……… …………………… Waveforms..!!! …………………….Loops ..!!!

Most Commonly used Waveforms and Loops…… : 

Most Commonly used Waveforms and Loops…… Pressure vs. Time Flow vs. Time Volume vs. Time AND Pressure – volume loop Flow – volume loop Flow - pressure loop…???

Slide 10: 

Spontaneous Breaths…. Mechanical Breaths…. Time volume Pressure FLOW Differentiate…………..

Types of Waveforms…… : 

Volume Modes Pressure Modes Types of Waveforms…… Pressure Flow Volume Time

Slide 12: 

Pressure Mode Pressure Flow Volume Time

Common features of Scalar WAVE forms….. : 

Common features of Scalar WAVE forms….. Scalars…….. on ordinate (vertical), Time…………on Abscissa (horizontal) Time line…BASE line where P, F and V are at zero level (FRC or basal alveolar level) Elevated base line only when CPAP/ PEEP is there.

Common features of Scalar WAVE forms….. : 

Inspiratory phase….Active…. affected by modes of vent. Expiratory phase….Passive NOT affected by mode of vent but by various characteristics of Resp system e.g. Resistance , compliance BUT.. Insp time can affect the duration of exp phase eg. In inverse ratio I:E Common features of Scalar WAVE forms…..

Common features of Scalar WAVE forms….. : 

While analyzing one has to keep in mind general principles of EXPONENTIAL functions applied to WAVEFORM graphics Each waveform has to be analyzed in terms of Magnitude, Duration, Pattern. Common features of Scalar WAVE forms…..

FLOW waveform……… : 

FLOW waveform……… Spont Br Pressure mode Zero flow Inspiration Expiration Time Flow PIF PEF What is flow?? How related to volume?? TI TE

Slide 17: 

Spont breath PRESSURE TIME waveform……… Pressure mode Time PIP PEEP Ti Pressure TE Insp Exp End Ex Pres

VOLUME TIME waveform ………. : 

VOLUME TIME waveform ………. Inspiration Expiration Time Volume TI TE Pressure mode

Slide 19: 

Variations and Abnormalities in waveforms…!!!! FLOW-TIME waveform…………….. PRESSURE – TIME waveform……. VOLUME-TIME waveform………….

Slide 20: 

P

FLOW waveform……… : 

FLOW waveform……… Pressure mode Zero flow Inspiration Expiration Time Flow PIF PEF TI TE

Identifies type of ventilation……………………… pressure vs. volume : 

Identifies type of ventilation……………………… pressure vs. volume Pressure… Volume….

Slide 23: 

Abnormalities of Flow waveform……… Inspiratory flow pattern…… I -time 1 : short 2 : Normal 3 : Prolonged Clinical significance……. ? Affects Tidal volume delivery Optimize Insp time

Slide 24: 

Flow termination sensitivity on Fixed I –time.. ……..prolonged

Inspiratory Cycle Off……. : 

Inspiratory Cycle Off……. The breath ends when the ventilator detects inspiratory flow has dropped to a specific flow value. Inspiration ends pressure flow

FLOW TERMINATION……Inspiratory Cycle Off…… : 

FLOW TERMINATION……Inspiratory Cycle Off…… In the above example, the machine is set to cycle inspiration off at 30% of the patient’s peak inspiratory flow. 100% of Patient’s Peak Inspiratory Flow Flow 100% 50% 30% 75%

Inspiratory Cycle Off…… : 

Inspiratory Cycle Off…… 60% 10% Exhalation spike A B 100% 100% Flow –termination classically seen in PSV……..

PSV…… : 

PSV…… Time (sec) Flow (L/m) Pressure (cm H2O) Volume (mL) Patient Triggered, Flow Cycled, Pressure limited Mode Identify mode…..

Slide 29: 

Expiratory flow pattern…… E-time

Air Trapping……… AUTO PEEP : 

Air Trapping……… AUTO PEEP Inspiration Expiration Time Flow (L/min) Air-trapping AUTO PEEP When expiratory flow doesn’t return to base line………and inspiration starts before exp ends….

Where we can find air-trapping…..? : 

Where we can find air-trapping…..? Pressure wave: while performing an expiratory hold, the waveform rises above baseline. Flow wave: the expiratory flow doesn’t return to baseline before the next breath begins. Volume wave: the expiratory portion doesn’t return to baseline. Flow/Volume Loop: the loop doesn’t meet at the baseline Pressure/Volume Loop: the loop doesn’t meet at the baseline

Measuring Auto -PEEP………. : 

Measuring Auto -PEEP……….

Auto-PEEP……. : 

Auto-PEEP……. Auto-PEEP = The averaged pressure by trapped gas in different lung units A dynamic entity may not present in all breath Short TE  air entrapment TE shorter than 3 expiratory time constant So it is a potential cause of hyperinflation

Response to Bronchodilator…. : 

Response to Bronchodilator…. Before Time Flow PEFR After Long TE Improved PEFR Shorter TE To assess response to bronchodilator therapy,…. 1. An increase in peak expiratory flow rate. 2. The expiratory curve should return to baseline sooner. Where else it can be observed…..??

Bronchodilator Response….. F-V loop : 

Bronchodilator Response….. F-V loop 2 1 1 2 3 3 V LPS . VT Normal AFTER Bronchospasm Relief 2 1 1 2 3 3 V .

Slide 36: 

PRESSURE waveform……… Pressure mode Time PIP PEEP Ti Pressure TE Insp Exp End Ex Pres

Slide 37: 

PRESSURE waveform……… Time PIP PEEP Ti Pressure TE To Increase Mean Airway Pressure…. 1. Increase flow 2. Increase peak pressure 3. Lengthen inspiratory time 4. Increase PEEP 5. Increase Rate      MAP…..

Slide 38: 

Time Pressure Assisted Controlled Identifying type of Breath/ mode of vent…………..

Slide 39: 

Is it a Volume or Pressure mode? Is it a Control or Support mode? Interpret the mode: Identify vent mode…. The pressure waveform has a plateau The flow waveform doesn't return to baseline P Mode Pressure support/CPAP

Slide 40: 

Is it a Volume or Pressure mode? Is it a Control or Support mode? Interpret the mode: Identify vent mode….

Slide 41: 

Set P level Time (sec) SIMV + PS + CPAP Pressure control ventilation Set P level CPAP level Identify mode……?

VOLUME waveform ………. : 

VOLUME waveform ………. Inspiration Expiration Time Volume TI TE Pressure controlled

How does it help…….??? : 

How does it help…….??? Air Leaks Setting appropriate I-time Weaning Active Exhalation

Air Leak………… : 

Volume (ml) Time (sec) A = exhalation that does not return to zero Air Leak…………

Where to look……? : 

Where to look……? Endotracheal Tube Leaks…… Volume waveform Pressure-volume loop Flow-volume loop

Air Leak………… : 

Air Leak………… VT ml 30 -10 V P F V P-V loop F-V loop Volume waveform….

Slide 47: 

1 2 3 4 5 6 0 15 cc Setting Appropriate I-Time ………. ……to get desired VT PCV…. PIP= 20, Vt (achieved) = 15 Short I – time ……low Vt volume Time Time

Slide 48: 

Setting Appropriate I-Time ………. Appropriate I – time ……good Vt volume Time Flow

Slide 49: 

PCV… SIMV A….Ineffective tidal volume in spontaneous breaths; B….Improved tidal volume during spontaneous breaths. Volume waveform … trending..guides for weaning

Active Exhalation…….. : 

Active Exhalation…….. Volume (ml) Time (sec)

Slide 51: 

The volume waveform is most commonly used to assess which two conditions? Answer: Air trapping and leaks

Loops……. : 

Loops……. Pressure-Volume Loops Flow-Volume Loops Flow-pressure loops ???

Common features of loops… : 

Common features of loops… Non-temporal loops …..cant’ predict time of loop but two variables are plotted simultaneously and inter-relationship is observed. These are called Loops since start of inspiration and end of expiration coincides at a point. There is NO agreed convention regarding the manner in which the loops are generated. Some devices draw them clockwise, others Anti clock wise. Some label upward deflections as negative, others positive.

P-V loops…… : 

P-V loops…… Lung Overdistention Airway Obstruction Bronchodilator Response Respiratory Mechanics WOB Flow Starvation Leaks Triggering Effort

Slide 56: 

inspiration expiration 15 30 5 The loop is almost square in PC/PS because of pressure limiting (constant) , during the inspiratory part of the loop. P-V Loop……. Components Volume Pressure P-V slope A = Inspiratory Resistance/ Resistive WOB B = Exp. Resistance/ Elastic WOB Dynamic Compliance Pressure mode…… PIP

P-V Loop……. Components : 

P-V Loop……. Components Volume PIP VT Pressure A = Inspiratory Resistance/ Resistive WOB B = Exp. Resistance/ Elastic WOB Expiration Inspiration Dynamic Compliance (Cdyn) The top part of the P/V loop represents Dynamic compliance (Cdyn). Cdyn = Δvolume/Δpressure Volume mode

Slide 58: 

Spontaneous Breath……… Inspiration Expiration 0 20 40 60 20 40 -60 0.2 0.4 0.6 Pressure cmH2O VT Clockwise CPAP

Slide 59: 

Assisted Breath………… Inspiration Expiration 0 20 40 60 20 40 -60 0.2 LITERS 0.4 0.6 Paw cmH2O Assisted Breath VT Clockwise to Counterclockwise PEEP

Slide 60: 

Controlled Breath……. Expiration 0 20 40 60 20 40 -60 0.2 LITERS 0.4 0.6 Paw cmH2O Inspiration VT Anticlockwise PEEP P-V loop and PEEP…..

P-V Loops….in Airway Resistance : 

P-V Loops….in Airway Resistance As resistance increases, the loop will become wider. An ↑ in expiratory resistance is more common. ↑ inspiratory resistance …….kinked ETT or patient biting. “hysteresis” exp. resistance insp. resistance

Decreased Compliance………. : 

Decreased Compliance………. Volume Pressure ↓compliance… Loops moves down (angle becomes < 40)…….RDS (HMD) ….moves up (>45) …….. ↑ compliance……. Surfactant therapy

Lung Compliance Changing in P-V Loop (pressure mode)…………. : 

Lung Compliance Changing in P-V Loop (pressure mode)…………. Volume Preset PIP VT levels Pressure RDS…lung 1.With surfactant 2. Emphysematous L Constant PIP……… variable VT

Lung Compliance Changes and the P-V Loop…. (Volume mode) : 

Lung Compliance Changes and the P-V Loop…. (Volume mode) Volume PIP levels Preset VT Pressure ↑C C ↓C Constant VT………. Variable Pressure

FRC and PV Loop : 

FRC and PV Loop VOLUME TLC Negative Positive 0 DISTENDING PRESSURE Normal Compliance FRC

Overdistension………. : 

Overdistension………. Volume Pressure Normal Abnormal With little or no change in VT Pressure rises C20 C dyne If C20/Cdyne ………..> 1……… Overdistension

Inadequate Sensitivity…………. : 

Inadequate Sensitivity…………. Volume (mL) Paw (cm H2O) Increased WOB

Slide 68: 

Flow vs Pressure triggering……… Inspiration Expiration 0 20 40 60 20 40 -60 0.2 0.4 0.6 Pressure cmH2O VT Clockwise Additional effort due To Pressure triggering

Air leak….. : 

Air leak….. The expiratory portion of the loop doesn’t return to baseline. This indicates a leak. Inspiration Expiration

Insufficient flow…… : 

Insufficient flow…… Volume Pressure Normal Insufficient Flow Cusping

P-V relationship curve…..loop : 

P-V relationship curve…..loop

Inflection Points : 

Inflection Points Pressure (cm H2O) Volume (mL)

Optimizing PEEP….. : 

Optimizing PEEP…..

Slide 74: 

Flow –Volume Loops……

Flow-Volume Loop………. : 

Flow-Volume Loop………. Volume (ml) Inspiration Expiration Flow (L/min) PIFR PEFR FRC VT Pressure Mode

F-V loops…. variations : 

F-V loops…. variations

Air-leak………. : 

Air-leak………. Volume (ml) Inspiration Expiration Flow (L/min) PIFR PEFR FRC VT Air Leak

Slide 78: 

Volume (ml) Inspiration Expiration Flow (L/min) PIFR PEFR VT Air Trapping……. Does not return to baseline

Airway Secretions ……….Water in the Circuit : 

Volume (ml) Inspiration Expiration Flow (L/min) PIFR PEFR FRC VT Airway Secretions ……….Water in the Circuit

Slide 80: 

Volume (ml) Inspiration Expiration Flow (L/min) PIFR FRC VT ↓PEFR “Scooped out” pattern Increased Airway Resistance……

Bronchodilator Response….. F-V loop : 

Bronchodilator Response….. F-V loop 2 1 1 2 3 3 V LPS . VT Normal AFTER Bronchospasm Relief 2 1 1 2 3 3 V .

Looking Trend Data…… : 

Looking Trend Data……

Slide 83: 

Experience is a wonderful thing. It enables you to recognize a mistake when you make it again………………………!!!

Slide 84: 

Thanks