Neonatal Pulmonary Graphics

Steven M.
Donn
Mark C. Mammel
Neonatal Pulmonary
Graphics
A Clinical Pocket Atlas
123
Neonatal Pulmonary
Graphics
Steven M. Donn • Mark C. Mammel
Neonatal Pulmonary
Graphics
A Clinical Pocket Atlas

Steven M. Donn, MD Mark C. Mammel, MD
Professor of Pediatrics Neonatal Medicine
Division of Neonatal-Perinatal Children’s Hospitals and Clinics
Medicine of Minnesota, St. Paul
C.S. Mott Children’s Hospital St. Paul, MN
University of Michigan USA
Health System
Ann Arbor, MI Professor of Pediatrics
USA University of Minnesota
Minneapolis, MN
USA
ISBN 978-1-4939-2016-7 ISBN 978-1-4939-2017-4 (eBook)

DOI 10.1007/978-1-4939-2017-4
Springer New York Heidelberg Dordrecht London
Library of Congress Control Number: 2014957872
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In memory of my parents: Elaine, a gifted
teacher who nurtured my interest in science and
mathematics, and Richard, a talented author who
inspired my love of writing and literature.
—SMD
To my late parents, Betty and Rusty, who always

believed I was smarter and more capable than
I am, and to my wife, Nancy, whose love and
understanding keeps me happy.
—MCM
Foreword
Clinicians have long struggled to make objective and

evidence-based decisions to optimize ventilatory support for
a sick and preterm neonate. Reliance on the interpretation of
arterial blood gases has been traditional and built upon sev-
eral decades of specialty experiences. The use of blood gas
data is primarily the result of clinical adaptation of physio-
logic principles. On the other hand, we are hampered by a
frequent inability to access arterial blood, especially in the
most vulnerable, very low birth weight infants. The relative
uselessness of capillary blood samples to estimate gas
exchange limit data on long-term beneficial outcomes, such
as permissive hypercapnia, and hampers our ability to mini-
mize ventilator-induced lung injury. Visualization of pulmo-
nary graphics, alone and concurrent with blood gas data to
define their respective relationships to respiratory support
settings, is akin to respiratory control, with these two afferent
inputs leading to the phrenic-nerve efferent response that
exists in mammalian respiratory systems (Fig. 1).
In this work, Donn and Mammel provide a clear and con-
cise stepwise instructional atlas to assist in our understanding
of direct and online visualization of the three fundamental
parameters of the respiratory system, namely, driving pres-
sure, air flow, and tidal volume. A clinician’s ability to use
these technologies to their full advantage will continue to
transform noninvasively derived information to acquired
knowledge to assess and manage neonatal pulmonary prob-
lems. When used as a resource in conjunction with arterial
blood gas data, chest radiography, and other clinical and
vii
viii Foreword
MD/RT
bedside
decisions
Interpretations Blood gas

of pulmonary analysis
graphics
Ventilator
settings
Figure 1 Clinical decision algorithm
laboratory information, pulmonary graphics can greatly

contribute to a clinician’s decision-making to optimize venti-
latory management and perhaps minimize ventilator-induced
lung injury.
This novel bedside atlas is a long-awaited toolkit for a non-
invasive point-of-care test for optimal neonatal ventilation.
Stanford, CA, USA Vinod K. Bhutani

Preface
We have witnessed tremendous technological advances since

the first neonatal patients were mechanically ventilated in
the late 1960s using modifications of devices built for adults.
Even after the advent of infant-specific ventilators, patient
assessment was rudimentary, consisting of the clinical exami-
nation and the occasional chest radiograph and blood gas
analysis. A key concept was missing in this initial approach.
The mechanical ventilator at that time worked best with a
passive subject. However, unless pharmacological paralysis
was used (which it often was), the spontaneously breathing
infant was anything but passive, trying to breathe while the
ventilator tried to assist, but seldom at the same time. The
concept of patient–ventilator interaction was born. First-
generation equipment to measure pulmonary mechanics
appeared in the late 1970s but was cumbersome, difficult to
calibrate, and often gave unreliable or irreproducible data.
The introduction of the microprocessor in the 1980s was a
giant leap forward, enabling breath-to-breath bedside assess-
ment of the baby and the ventilator for the first time. This
included measurements and displays of valuable information
about lung mechanics, patient–ventilator synchrony, and the
response to different ventilation strategies and pharmaco-
logical interventions. Ventilation of the neonatal patient
finally moved from “one size fits all” to customized strategies
based on the underlying pathophysiology and the baby’s
response to intervention.
Although bedside assessment of lung mechanics and
patient–ventilator interaction initially relied on stand-alone
ix
x Preface
devices with a display screen and portable computer that was

tediously rolled from bed to bed, by the 1990s ventilator
manufacturers began to recognize the need for continuous
monitoring and added graphic monitors to mechanical venti-
lators. This allowed a visual representation of what was hap-
pening with—and between—each ventilator cycle. Clinicians
became able to diagnose conditions like gas trapping before
it resulted in air leak and to evaluate the best mode or modal-
ity for the individual patient. Unfortunately, there was a lack
of both acceptance and understanding of pulmonary graphics
as an adjunct to mechanical ventilation. Surprisingly, many
today are still uncertain how this real-time information
should be used to understand and manage neonatal respira-
tory treatments.
We undertook this project to further the understanding of
pulmonary graphics. Graphics are all about pattern recogni-
tion. We have assembled an atlas of patterns commonly
encountered in neonatal practice in a format that displays
actual screenshots with an accompanying schematic, which
dissects the graphic and illustrates its key features. The chap-
ters have been arranged to demonstrate the principles of
real-time pulmonary graphics, a discussion of waveforms and
loops, and how they are both affected by mechanical ventila-
tion and disease states. We conclude with a series of clinical
cases to illustrate some key points.
We are indebted to a number of individuals who made this
project possible. We would like to thank our publisher,
Springer Science+Business Media, LLC; Shelley Reinhardt,
our Senior Editor; Lee Klein, our developmental editor; as
well as the illustrators who produced the schematic drawings.
We would like to acknowledge the efforts of Michael Becker
of C.S. Mott Children’s Hospital at the University of Michigan,
and Cathy Worwa and Pat Meyers at Children’s Hospitals &
Clinics of Minnesota in St. Paul, who helped generate many
of the real-time screenshots. We also recognize the roles of
Joanne Nicks, a colleague in respiratory therapy at Michigan,
and Dennis Bing, the head respiratory therapist for many
years at Children’s in St. Paul, who collaborated on our early
Preface xi
experiences with pulmonary graphics as we spent many excit-

ing hours really learning respiratory physiology. We have
both been fortunate to work with forward-thinking neona-
tologists, in particular the late Stephen Boros, who saw the
potential value of graphics and enabled us to pursue our
work in this area.
It is our hope that this atlas will be of assistance in the
management of neonatal ventilation and will lead to better
and safer outcomes for your patients.
Ann Arbor, MI, USA Steven M. Donn, MD

St. Paul, MN, USA Mark C. Mammel, MD
Contents
1 Principles of Real-Time Pulmonary Graphics . . . . . . 1

1.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Principles of Pulmonary Graphics . . . . . . . . . . . 2
1.3 The Graphic Screen . . . . . . . . . . . . . . . . . . . . . . . 4
1.4 Limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2 Waveforms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.2 Volume Waveform. . . . . . . . . . . . . . . . . . . . . . . . . 10
2.3 Pressure Waveform . . . . . . . . . . . . . . . . . . . . . . . . 14
2.3.1 Plateau Pressure . . . . . . . . . . . . . . . . . . . . 16
2.3.2 Changes in PIP and PEEP. . . . . . . . . . . . 18
2.3.3 Change in Inspiratory Time. . . . . . . . . . . 20
2.3.4 Pressure Overshoot . . . . . . . . . . . . . . . . . 22
2.4 Flow Waveform . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
2.4.1 Increased Expiratory Resistance . . . . . . 28
2.4.2 Gas Trapping . . . . . . . . . . . . . . . . . . . . . . . 28
2.4.3 Cycling Mechanisms. . . . . . . . . . . . . . . . . 30
2.4.4 Endotracheal Tube Leaks . . . . . . . . . . . . 34
2.4.5 Auto-cycling (Auto-triggering) . . . . . . . . 36
2.4.6 Flow Rate and the Shape
of the Flow Waveform. . . . . . . . . . . . . . 38
2.4.7 Spontaneous Breath. . . . . . . . . . . . . . . . . 42
3 Impact of Mechanical Ventilation on Waveforms . . . 45

3.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
3.2 Ventilator Modes. . . . . . . . . . . . . . . . . . . . . . . . . . 45
xiii
xiv Contents
3.2.1 IMV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
3.2.2 SIMV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
3.2.3 Assist/Control (A/C) . . . . . . . . . . . . . . . . 52
3.2.4 PSV. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
3.3 Techniques to Alter Mean Airway Pressure . . . 60
3.3.1 Change in PIP . . . . . . . . . . . . . . . . . . . . . . 64
3.3.2 Change in PEEP . . . . . . . . . . . . . . . . . . . . 66
3.3.3 Change in Ti . . . . . . . . . . . . . . . . . . . . . . . . 70
3.3.4 Change in Rate . . . . . . . . . . . . . . . . . . . . . 72
4 Pulmonary Mechanics and Loops . . . . . . . . . . . . . . . . 75

4.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
4.2 The P-V Loop . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
4.2.1 Decreased Compliance . . . . . . . . . . . . . . 78
4.2.2 Lung Inflation . . . . . . . . . . . . . . . . . . . . . . 82
4.2.3 Hyperinflation. . . . . . . . . . . . . . . . . . . . . . 82
4.2.4 Underinflation. . . . . . . . . . . . . . . . . . . . . . 86
4.2.5 Pressure Overshoot . . . . . . . . . . . . . . . . . 90
4.2.6 Air Hunger . . . . . . . . . . . . . . . . . . . . . . . . 96
4.2.7 Increased Inspiratory Resistance . . . . . . 98
4.2.8 Increased Expiratory Resistance . . . . . . 100
4.2.9 Surfactant Administration. . . . . . . . . . . . 102
4.2.10 Excessive Inspiratory Hold . . . . . . . . . . . 106
4.3 The F-V Loop . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
4.3.1 Elevated Inspiratory Resistance. . . . . . . 112
4.3.2 Elevated Expiratory Resistance . . . . . . . 114
4.3.3 Fixed Airway Obstruction . . . . . . . . . . . . 116
4.3.4 Evaluation of Bronchodilator Therapy . . 118
4.3.5 Excessive Dynamic Airway Collapse. . . 122
5 Trend Screens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125

6 Miscellaneous Conditions . . . . . . . . . . . . . . . . . . . . . . . 133

6.1 Endotracheal Tube Leaks . . . . . . . . . . . . . . . . . . 134
6.2 Turbulence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Contents xv
7 Clinical Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143

7.1 Case 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
7.2 Case 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
7.3 Case 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
7.4 Case 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
7.5 Case 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
7.6 Case 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
7.7 Case 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
7.8 Case 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
7.9 Case 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
7.10 Case 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
7.11 Case 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
8 Further Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Erratum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E1
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Chapter 1
Principles of Real-Time
Pulmonary Graphics
1.1 Introduction
For nearly a quarter of a century, newborns requiring
mechanical ventilation were managed primarily by clinical
means, supplemented with intermittent laboratory data pro-
vided by blood gas analysis and chest radiography. Little was
known about pulmonary mechanics or the interactions
between the baby and the ventilator. During this era, the
“gold standard” of pulmonary mechanics, incentive spirome-
try, had no practical utility in the neonatal population.
Early attempts to bring pulmonary function testing to the
neonatal intensive care unit (NICU) were equally frustrat-
ing. The equipment was extraordinarily cumbersome,
required painstaking calibration, and often provided data
that were not interpretable. Major advances in technology in
the mid-1980s ushered in the era of the practical portable
computer, allowing for the first time bedside evaluation of
gas flow patterns with simultaneous pressure and volume
waveforms in critically ill newborns. Because these devices
were stand-alone, and not incorporated into the ventilators
themselves, the technique was limited to intermittent sam-
pling, because the devices had to be taken from bed to bed
and could not be used continuously. By the early 1990s
microprocessor-based ventilation, as well as the introduction
of real-time pulmonary graphics, made continuous monitoring
S.M. Donn, M.C. Mammel, Neonatal Pulmonary Graphics: 1

A Clinical Pocket Atlas, DOI 10.1007/978-1-4939-2017-4_1,
2 Chapter 1. Principles of Real-Time Pulmonary Graphics
and tracking of both pulmonary mechanics and trends pos-

sible. For the first time, neonatal clinicians were able to see
breath-to-breath displays of pulmonary waveforms and
“loops,” to have the benefits of data trending and storage,
and to objectify the results of treatments with narrow thera-
peutic indices.
1.2 Principles of Pulmonary Graphics

Pulmonary graphic monitoring systems are composed of mul-
tiple units that work together to create a visual or numerical
display. Figure 1.1 demonstrates a schematic diagram of the
key components.
The signals of interest, such as flow and pressure, are con-
verted by a transducer into electrical analogues. The instru-
ment is now generally automatically calibrated, and filters
remove noise and interference. The analogue signal is con-
verted to a digital format (signal processing) and sent to the
computer for data analysis. The end result is a measured sig-
nal, either numeric or graphic, that is then subjected to clini-
cal interpretation.
The transducer, also referred to as a sensor, is a light-
weight, low dead-space device that is inserted at the proxi-
mal airway (Fig. 1.2). Today most mechanical ventilators
utilize the heated wire anemometer technology. A platinum,
tungsten, or platinum-iridium wire at the center of the sen-
sor is heated to a fixed temperature. As gas flows over the
wire, cooling it, additional electricity must be supplied to
bring the wire back to its fixed temperature. The amount of
current this requires can then be converted to flow and vol-
ume signals. For bi-directional flow determination, a second
wire can be added. Both inspiratory and expiratory pres-
sures can be measured by transducers located within the
ventilator or through the use of an accessory transducer at
the proximal airway, which improves the accuracy of
measurement.
1.2 Principles of Pulmonary Graphics 3
Figure 1.1 Schematic flow diagram demonstrating signal process-

ing, display, and analysis of pulmonary graphics
Figure 1.2 Proximal airway sensor (transducer)

1.3 The Graphic Screen

A typical graphic monitor screen is depicted in Fig. 1.3. A
schematic representation is shown on the top (Fig. 1.3a) and
an actual representation is shown on the bottom (Fig. 1.3b).
On the left side of the screen, the column of numbers display
actual measured values. The clinician can select any parame-
ters of interest. The row of numbers at the bottom of the
screen displays the ventilatory parameters chosen by the cli-
nician. The center of the screen can be used to display wave-
forms, loops, a trend screen, or a numeric monitor screen
(these are discussed in detail later).
Most monitors utilize color displays, which can be very
useful in the interpretation of the data. This particular moni-
tor distinguishes inspiration from expiration by color coding.
Inspiration is drawn in red if it is machine initiated and in
yellow if it is patient initiated. Expiration is drawn in blue.
Occasionally a green line appears, indicating that the device
is auto-calibrating.
1.3 The Graphic Screen 5
a PRESSURE A/C MAIN
40
20
Paw (cmH2O)
cmH2O 20
Ppeak
0
30
bpm
–20
2 4 6 8 10 12
Rate 10
Flow (L/min)
20.4
mL
5
0
2 4 6 8 10 12
Vti –5
–10
17.9
mL 30
Vte
20
Vt (mL)
6.6
mL/kg
10
0
Vti/kg 2 4 6 8 10 12
–10
30 16 0.35 4 0.5 40
bpm cmH2O sec cmH2O L/min %
Rate Insp Press Ins Time PEEP Flow Trig FiO2
0.35 sec 1.65 sec
1:4.7
Figure 1.3 Typical graphic monitor screen (a, schematic; b, actual). In

this example, the measured parameters pressure, rate, inspiratory vol-
ume, expiratory volume and inspiratory volume/kg are shown on the
vertical axis; the individual parameters are often customizable, and
others may be displayed. Parameters set by the operator are shown on
the horizontal axis; in this example they include rate, inspiratory pres-
sure, inspiratory time, PEEP, flow trigger, and FiO2. These are usually
established by the manufacturer and may not be substituted. A com-
parison of the two allows the user to determine what (if any) contribu-
tion the patient is able to make to the set support values
Not all devices contain an auto-scale function. When pres-

ent, auto-scaling selects the appropriate axes for waveforms
and loops and makes pattern recognition easier. Without
auto-scaling, the clinician must pay close attention to the axes
and adjust them accordingly. The axes should be set to con-
tain the entire waveform or loop and should be as close to a
1:1 ratio as possible.
1.4 Limitations
A major drawback is that the equipment required to measure
and display pulmonary mechanics and graphics has not been
standardized. Interpretation of pulmonary graphics requires
pattern recognition. Unfortunately, this can be distorted by
improper scaling of axes, and even the direction of flow-
volume loops can be either clockwise or counterclockwise.
Some reference values are still lacking. Significant inter- and
intra-patient variability has been reported. Clinicians need to
be mindful that what is being measured is the mechanical
properties of the lungs and airways (pulmonary mechanics),
and not true gas exchange (pulmonary function). Finally, we
must be cognizant that the use of uncuffed endotracheal
tubes will result in some degree of leak, and this can have an
important impact on how the system functions.
Suggested Reading
Bhutani VK, Sivieri EM, Abassi S, Shaffer TH. Evaluation of neona-
tal pulmonary mechanics and energetics: a two factor least mean
square analysis. Pediatr Pulmonol. 1988;4:150–8.
DeVries DF, Baker L. Basic engineering concepts in pulmonary
graphics. In: Donn SM, editor. Neonatal and pediatric pulmonary
graphics: principles and clinical applications. Armonk: Futura;
1998. p. 35–56.
Gerhardt TO. Limitations and pitfalls of pulmonary function testing
and pulmonary graphics in the clinical setting. In: Donn SM, edi-
tor. Neonatal and pediatric pulmonary graphics: principles and
clinical applications. Armonk: Futura; 1998. p. 129–53.
Chapter 2
Waveforms

8 Chapter 2. Waveforms
2.1 Introduction
Waveforms depict the relationship between respiratory
parameters and time on a breath-to-breath basis. The three
most commonly used signals are pressure (cm H2O), volume
(mL), and flow (mL/s), and these three signals describe the
respiratory cycle. Most graphic monitors are now capable of
displaying all three waveforms simultaneously; some display
only one or two.
When displayed in aggregate, the cyclic phases of respira-
tion can be appreciated. Each waveform has distinct points of
initiation of inspiration, peak inspiration, end of inspiration/
initiation of expiration, and end of expiration. These are
depicted schematically in Fig. 2.1a and actually in Fig. 2.1b.
2.1 Introduction 9
a Paw (cmH2O) 40
20
0
2 4 6 8 10 12
–20
10
Flow (L/min)
5
0
2 4 6 8 10 12
–5
–10
30
20
Vt (mL)
10
0
2 4 6 8 10 12
–10 A B C D
Figure 2.1 Pulmonary waveforms (a, schematic; b, actual). Pressure

waveforms are displayed on top, flow waveforms are on the middle
panel, and volume waveforms are on the bottom. Point A represents
the initiation of inspiration. Point B is peak inspiration. Point C rep-
resents the end of inspiration and start of expiration. Point D is the
end of expiration
2.2 Volume Waveform

The volume waveform displays the changes in delivered
volume over time. It is determined by integrating the inspira-
tory and expiratory flow signals. A typical volume waveform
is shown in Fig. 2.2. As seen in Fig. 2.2a, the waveform has
several reference points. Point A depicts the initiation of
inspiration. Point B represents the maximum inspired gas vol-
ume. Point C represents the end of inspiration and the start
of expiration. Point D depicts end-expiration volume and
should be very close to the zero volume line; expired volume
is usually a bit less than inspired volume because of air leak
around the uncuffed neonatal endotracheal tube. An actual
volume waveform is shown in Fig. 2.2b.
2.2 Volume Waveform 11
a 30
B
20
Vt (mL)
C
10
0
2 4 6 8 10 12
–10
A
Figure 2.2 Volume waveform (a, schematic; b, actual). Point A is the

start of inspiration. Point B represents the maximum inspired gas
volume. Point C is the end inspiratory volume
Evaluation of the tidal volume (Vt) waveform may be use-

ful in determining the relative contributions of mechanical
and spontaneous breaths during intermittent mandatory or
synchronized intermittent mandatory ventilation (SIMV).
Figure 2.3 demonstrates this. Note that the larger volume
breaths are SIMV, and the smaller breaths, supported only by
positive end-expiratory pressure (PEEP), are spontaneous.
2.2 Volume Waveform 13
a Paw (cmH2O)
40
20
0
1 2 3 4 5
–20
6
Flow (L/min)
3
0
1 2 3 4 5
–3
–6
30
20
Vt (mL)
10
0
1 2 3 4 5
–10
A B A A B B B
Figure 2.3 Waveforms obtained during SIMV/pressure support ven-

tilation. Note the relative contributions during SIMV (waveforms
connoted by A) and partial pressure support (waveforms connoted by
B) in schematic (a) and actual (b) waveforms. In this example, since
pressure support is set at 0, we see no pressure deflection (since no
positive pressure is being added to support spontaneous breaths) but
we do see the flow and volume changes initiated by the patient
2.3 Pressure Waveform

The pressure waveform represents the airway pressure
throughout the respiratory cycle (Fig. 2.4). Virtually every
newborn requiring conventional mechanical ventilation
receives some degree of PEEP. Thus, the waveform at end
inspiration or the initiation of inspiration is above the base-
line (zero) value. Pressure rises during inspiration, reaching
its maximum value, or peak inspiratory pressure (PIP), then
declines during expiration to the PEEP level. The area under
a single cycle represents the mean airway pressure (mean
Paw). The difference between the PIP and the PEEP is
referred to as the amplitude or delta P. These are shown sche-
matically (Fig. 2.4a) and actually (Fig. 2.4b).
2.3 Pressure Waveform 15
PIP
PAW
PEEP
Figure 2.4 Schematic representation of the anatomy of a pressure

waveform (a). The amplitude or ΔP is the difference between the
peak inspiratory pressure (PIP) and the baseline pressure, referred to
as the positive end-expiratory pressure (PEEP). The mean airway
pressure is represented by the area under the curve (shaded area) for
a single waveform. An actual pressure waveform is depicted in (b)
2.3.1 Plateau Pressure
If an inspiratory hold is used to prolong the inspiratory time

(preventing the exhalation valve from opening), a plateau
pressure may develop. This is shown in Fig. 2.5. After reaching
the PIP, rather than linearly decreasing to the baseline, it
remains constant, creating the plateau, until the hold ends
and the exhalation valve opens.
a PP
Figure 2.5 Plateau pressure. Prolonging inspiratory time by use of

an inspiratory hold produces a pressure plateau (PP), demonstrated
schematically (a) and actually (b)
2.3.2 Changes in PIP and PEEP
Changes in either PIP or PEEP will change the shape of the

pressure waveform and alter the delivered mean Paw. Figure 2.6
represents the index ventilator settings, where the PIP is 20 cm
H2O and the PEEP is 5 cm H2O. Figure 2.7 demonstrates the
change when the PIP is increased to 30 cm H2O. If the PEEP
remains unchanged, the amplitude will increase by 10 cm H2O.
Changes in PIP without concomitant changes in PEEP will
alter the amplitude. Here, our initial settings are again PIP
20 cm H2O and PEEP 5 cm H2O (Fig. 2.6). When the PEEP
is increased to 10 cm H2O while the PIP is held constant, note
how the baseline rises and the difference from PIP to PEEP
decreases (Fig. 2.8).
a Paw (cmH2O) 40
20
0
2 4 6 8 10 12
–20
Figure 2.6 Index pressure waveform (a, schematic; b, actual). PIP is

20 cm H2O, PEEP is 5 cm H2O
a 40
Paw (cmH2O)
20
0
2 4 6 8 10 12
–20
Figure 2.7 In this pressure waveform (a, schematic; b, actual), the

PIP has been increased to 30 cm H2O (arrow)
a 40
Paw (cmH2O)
20
0
2 4 6 8 10 12
–20
Figure 2.8 In this example, the PEEP has been increased from 5 to
10 cm H2O (arrow). Note the rise in the baseline and decrease in the
amplitude (a, schematic; b, actual)
2.3.3 Change in Inspiratory Time
Increasing the inspiratory time will increase the duration of

positive pressure and will lengthen the inspiratory phase of
the pressure waveform. If all other parameters are held con-
stant, the mean Paw will increase (the area under the curve
enlarges). Figure 2.9 shows changes in the pressure waveform
after increasing the inspiratory time from that seen in Fig. 2.6.
Note the increased length of the inspiratory phase of the
waveform and the increased area under the curve.
a Paw (cmH2O) 40
20
0
2 4 6 8 10 12
–20
c 40
Paw (cmH2O)
20
0
2 4 6 8 10 12
–20 TI
Figure 2.9 Increasing the inspiratory time increases the area under
the curve, and hence, the mean airway pressure. The upper wave-
forms (a, schematic; b, actual) show a PIP of 20, PEEP 5 with a short
Ti; the lower waveforms (c, schematic; d, actual) show how a longer
Ti changes the inspiratory pressure waveform and increases mean
airway pressure
2.3.4 Pressure Overshoot
Pressure control and pressure support ventilation utilize an

accelerating-decelerating inspiratory flow waveform (dis-
cussed later). If set too high, it may deliver pressure too rap-
idly for the patient’s need. This creates a condition known as
pressure overshoot (sometimes called “ringing”). Figure 2.10
displays this. The pressure waveform exhibits a notch and
double peak at PIP. Most ventilators have an adjustable rise
time function to respond to this. It is a semi-quantitative
means of reducing the inspiratory flow rate.
a 10
A A A
0
V
–10
0.00 sec 1 2 3 4 5
30 B B B
Paw
–10
Figure 2.10 Pressure overshoot (a, schematic; b, actual). If the rise time
produces an excessive flow rate during pressure control or pressure sup-
port ventilation, pressure overshoot, also known as “ringing,” may occur.
This can be seen on the flow waveform as a “bump” at the end of inspira-
tory flow (A) and as a notch at the top of the pressure waveform (B)
2.4 Flow Waveform

The flow waveform is the most complex because its inspira-
tory and expiratory phases each have two components. In this
waveform, the baseline represents a zero flow state, meaning
that no gas is entering or leaving the airway. By convention,
anything above the baseline (positive value) represents inspi-
ratory flow (gas flow into the patient), and conversely, any-
thing below the baseline (negative value) represents
expiratory flow (gas flow from the patient). The anatomy of a
flow waveform during pressure-targeted ventilation is
depicted schematically in Fig. 2.11a. Keep in mind that flow is
the time rate of volume delivery.
There are two major ways in which inspiratory flow can be
delivered to the patient, variable or constant (continuous)
flow. Variable flow is utilized in pressure control and pressure
support ventilation. As inspiration begins, there is a sharp
upward rise, or acceleration, in inspiratory flow. At its maxi-
mal value, it is referred to as peak inspiratory flow. This is the
fastest rate at which gas enters the airway. Thereafter, flow
decelerates to the baseline value, reaching zero when the
lungs are filled and no further gas enters the airway. Even
though the slope (direction) of the decelerating phase differs
2.4 Flow Waveform 25
a 2 B
1 A C
Flow (L/min)
D
0
H 4 6 8 10 12
1
–1 G
E
–2
F
Figure 2.11 Anatomy of a flow waveform (a, schematic; b, actual).

As the breath begins, there is an acceleration of inspiratory flow
from the zero flow baseline (A) to its maximal value, the peak inspi-
ratory pressure (B). Flow then decelerates (C) back to the zero flow
baseline, where inspiration ends (D). Flow then reverses in expira-
tion, as gas flow out of the airway accelerates (E), reaches its peak
expiratory flow rate (F), then slows (decelerates) (G) until flow
ceases at end-expiration (H). Thus, there are four phases- accelerat-
ing inspiratory flow, decelerating inspiratory flow, accelerating expi-
ratory flow, and decelerating expiratory flow
from the accelerating phase, both are above the baseline and
represent gas flow into the patient, but at different rates. Note
that the time from one zero flow state to the next defines the
inspiratory time. When a continuous inspiratory flow modal-
ity, such as volume control, is used, the inspiratory flow accel-
erates to a peak level and then is held constant for the
duration of inspiration, decelerating only after the exhalation
valve opens. This creates a characteristic “square” waveform.
The expiratory phase of the flow waveform is similar, but in
the opposite direction. As expiration begins, there is a rapid
acceleration of expiratory flow, and the most rapidly moving
gas from the airway is seen at the peak expiratory flow rate
(the deepest negative deflection). This is followed by a decel-
eration of expiratory flow until the lung is emptied to func-
tional residual capacity and a zero flow state is achieved.
Again, although the direction of the accelerating and deceler-
ating components is different, they are both below the base-
line (negative) and both represent expiratory flow. The
distance between the zero flow states represents the expira-
tory time. An actual flow waveform during pressure control
ventilation is depicted in Fig. 2.11b. Note the sharply acceler-
ating inspiratory flow, peak inspiratory flow, decelerating
inspiratory flow, and zero flow at end-inspiration. Expiration
then ensues, with accelerating expiratory flow, peak expira-
tory flow, and decelerating expiratory flow. The expiratory
phase ends at a zero flow state.
Figure 2.12 shows a flow waveform during volume control
ventilation. The accelerating inspiratory flow peaks and then
is held constant (continuous) until inspiration ends, creating
a square waveform.
a 2
1
Flow (L/min)
0
2 4 6 8 10 12
1
–1
–2
Figure 2.12 Flow wave form during volume control ventilation

(a, schematic; b, actual). Inspiratory flow is continuous, rather than
variable, and produces a characteristic “square” waveform
2.4.1 Increased Expiratory Resistance
Increased expiratory resistance will decrease expiratory gas

flow. This results in a longer time for the lung to empty and is
depicted graphically by either shallow accelerating expira-
tory flow and decreased peak expiratory flow rate, a longer
time to return to baseline during decelerating expiratory
flow, or both. These changes are shown in Fig. 2.13. Note the
shallow accelerating expiratory flow with decreased peak
expiratory flow and the prolonged time to return to the base-
line during decelerating expiratory flow.
2.4.2 Gas Trapping
Gas trapping occurs when the expiratory flow is less than the
inspiratory flow, resulting in more gas entering than leaving
the lung. This is a potentially dangerous situation that can
lead to alveolar rupture and air leak. Prior to the advent of
real-time graphics, clinicians were usually aware of gas trap-
ping only after the air leak had occurred. Now, careful obser-
vation of the flow waveform can detect this condition,
allowing time to avoid its consequences.
In the panel shown in Fig. 2.14, note that in each flow
waveform, the decelerating expiratory component never
reaches the baseline (zero flow state) before the subsequent
breath is initiated and the accelerating inspiratory flow
occurs. Possible adjustments might include decreasing the
ventilator rate, decreasing the flow rate, shortening the inspi-
ratory time, or increasing the PEEP, depending upon the
clinical condition, ventilator modality, and underlying
pathophysiology.
a 6
3
Flow (L/min)
0
2 4 6 8 10 12
–3
–6
Figure 2.13 Flow waveform depicting increased expiratory resis-

tance (a, schematic; b, actual). Note the decreased slope and
increased time for the decelerating portion of the expiratory flow to
return to the baseline (arrows)
a 6
3
Flow (L/min)
0
2 4 6 8 10 12
–3
–6
Figure 2.14 Gas trapping (a, schematic; b, actual). Note that the
expiratory flow fails to reach the baseline (zero flow state) before
the next breath is initiated (circle)
2.4.3 Cycling Mechanisms
Cycling refers to the mechanism that transitions inspiration to

expiration and expiration to inspiration. For decades, neonatal
ventilators offered only time as the cycling mechanism. The
clinician chose an inspiratory time or an inspiratory:expiratory
ratio. The exhalation valve would close and pressure and flow
would be delivered until the exhalation valve opened at the
end of the inspiratory time. During time cycling (Fig. 2.15),
note that the inspiratory time is identical for each breath and
that there may be a prolongation of the zero flow state at
the end of inspiration if all of the breath conditions (such as
peak pressure) have been met prior to the completion of the
inspiratory time.
The advent of microprocessor-controlled ventilation offered
new cycling mechanisms, particularly flow-cycling of neonatal
patients. Flow-cycling can be applied to pressure-targeted
modalities, such as pressure-limited ventilation, pressure con-
trol ventilation, and pressure support ventilation.
a 6
3
Flow (L/min)
0
2 4 6 8 10 12
Ti Ti
–3
–6
Figure 2.15 Time cycling (a, schematic; b, actual). For each breath,
inspiration lasts for a set period of time until the exhalation valve
opens. Note that there may be no flow going into the airway at end-
inspiration (arrows)
Flow-cycling takes advantage of the natural pattern of

breathing by focusing on the baby’s inspiratory flow (Fig. 2.16).
As a breath is delivered, the ventilator notes the peak inspira-
tory flow rate. The inspiratory flow rate then decelerates, but
before it completely reaches the zero flow state, the exhala-
tion valve will open, discharging the remainder of inspiratory
flow. The exact point at which this happens is determined by
both the specific ventilator algorithm and the clinician-chosen
termination point. Generally, this is at 5–25 % of the peak
inspiratory flow rate. There are two major advantages to flow-
cycling. First, it theoretically enables 100 % synchrony between
the baby and the ventilator because the baby both initiates
and terminates the breath (the effect of lag time between the
actual patient effort, the onset of flow, and signal transfer time
may still result in imperfectly triggered breaths). Second, it
prevents gas trapping and the inversion of the
inspiratory:expiratory ratio during patient-triggered ventila-
tion. During time-cycled, patient-triggered ventilation, because
the inspiratory time is fixed, the faster a baby breathes, the
shorter will be the expiratory time and the greater the ratio
will be. At very rapid rates, the risk of gas trapping increases.
If flow-cycling is used, the ratio will be preserved because
each breath will be terminated at a percentage of the peak
inspiratory flow rate, thus shortening inspiration.
Flow-cycling is used in conjunction with time-cycling, in
that a breath will be terminated by whichever condition
occurs first. In pressure support ventilation, the inspiratory
time is a “time limit,” which cannot be exceeded.
a 6
3
Flow (L/min)
0
2 4 6 8 10 12
–3
–6
Figure 2.16 Flow cycling (a, schematic; b, actual). During flow

cycled breaths, inspiration ends when inspiratory flow has deceler-
ated to a small percentage of the peak inspiratory flow rate, and the
breath cycles directly into expiration (arrows)
2.4.4 Endotracheal Tube Leaks
Because cuffed endotracheal tubes are not used in newborns,

there will almost always be some degree of leak around the
endotracheal tube. Most of this occurs during inspiration
when pressure is higher. Although leaks are easiest to recog-
nize on the Vt waveform (Fig. 2.17) or the pressure-volume
and flow-volume loops (see later), their importance can be
seen by examining their effect on the flow waveform during
flow-cycling.
A significant leak may divert gas flow, such that the
decelerating inspiratory flow may never reach the termina-
tion point. The breath will then be time-cycled, but often with
inadequate pressure or volume delivered to the baby.
a Paw (cmH2O)
20
10
0
2 4 6 8 10 12
–10
6
Flow (L/min)
3
0
2 4 6 8 10 12
–3
–6
15
10
Vt (mL)
0
2 4 6 8 10 12
–5
Figure 2.17 Large endotracheal tube leak (a, schematic; b, actual).

The flow waveform, shown in the middle panel, has virtually no expi-
ratory component. The volume waveform, in the lower panel, shows
almost no expired volume (the actual end of the expiratory volume
waveform is shown by the arrows in the schematic, and by the short
blue line in the actual tracing) which is followed by a reset artifact
(yellow colored line dropping to the zero baseline). This also results
in auto-cycling, with a rate of 75
2.4.5 Auto-cycling (Auto-triggering)
Auto-cycling (also referred to as auto-triggering) may occur

during flow-triggered ventilation if the ventilator interprets an
aberrant flow signal as patient effort. This can happen if there
is a leak that exceeds the trigger threshold, and it may occur
anywhere in the path of gas flow (e.g., ventilator circuit,
humidifier, endotracheal tube). It may also occur from exces-
sive condensation in the ventilator circuit (“rainout”). As this
fluid shifts back and forth during ventilator cycling, it may
create a flow change sufficient to trigger the ventilator. When
auto-cycling occurs, there may be rapid delivery of mechanical
breaths, inducing hypocapnia as well as the risk of lung injury.
Figure 2.18 shows a flow waveform panel during auto-
cycling. It may be distinguished from rapid breathing that is
actually patient-initiated. During some types of auto-cycling,
all of the breaths are identical—there is no variation in their
rate or periodicity. For others, such as the movement of water
in the tubing, the rate may vary and be more challenging to
identify. Even a rapidly breathing baby will show some varia-
tion in the rate of breathing and the appearance of the flow
waveform.
a 6
3
Flow (L/min)
0
1 2 3 4 5 6
–3
–6
Figure 2.18 Another example of auto-cycling (a, schematic; b, actual).

Significant leaks during flow-triggered ventilation may reach the assist
sensitivity threshold and result in repetitive delivery of mechanical
breaths. Note the relative uniformity of the breaths, which helps to
distinguish this from just rapid breathing, where there will be some
variability
2.4.6 Flow Rate and the Shape of the Flow

Waveform
The manner in which flow is delivered to the patient will
determine its shape. Inspiratory flow may be continuous, as in
pressure-limited ventilation or volume control ventilation, or
it may be variable, as in pressure control or pressure support
ventilation.
Continuous flow in pressure-limited ventilation produces
a sinusoidal flow waveform with a rounded contour. This is
shown in Fig. 2.19.
Continuous flow during volume ventilation produces a
square flow waveform (Fig. 2.20). Flow accelerates at the
initiation of inspiration but is held constant until inspiration
ends.
a 10
5
Flow (L/min)
0
2 4 6 8 10 12
–5
–10
Figure 2.19 Pressure limited ventilation (a, schematic; b, actual).

Continuous inspiratory flow produces a more sinusoidal flow waveform
a 2
1
Flow (L/min)
0
2 4 6 8 10 12
–1
–2
Figure 2.20 Volume control ventilation (a, schematic; b, actual).

Constant inspiratory flow produces a square flow waveform
Variable inspiratory flow produces a waveform that rapidly

accelerates and peaks then decelerates (Fig. 2.21). It is used in
pressure control and pressure support ventilation and is typi-
cally “spiked.” Although its shape is determined primarily by
the ventilator algorithm, it may be modulated through a fea-
ture known as rise time. Figure 2.22 shows a flow waveform
has been modulated by adjusting the rise time, decreasing the
inspiratory flow rate, and producing a less spiked shape.
a 2
A
1
Flow (L/min)
0
2 4 6 8 10 12
–1
–2
Figure 2.21 Pressure control or pressure support ventilation

(a, schematic; b, actual). Variable inspiratory flow produces a rapidly
accelerating (A) and decelerating inspiratory flow waveform, some-
times referred to as a “spike” waveform
a 20
Paw (cmH2O)
10
0
1 2 3 4 5 6
–10
A
3
Flow (L/min)
0
1 2 3 4 5 6
–3
–6
Figure 2.22 Adjustment of rise time modulates the inspiratory flow

rate during pressure control or pressure support ventilation (a, sche-
matic; b, actual). Note that the slope of the accelerating inspiratory
flow (A) is less than in Fig. 2.21
2.4.7 Spontaneous Breath
Figure 2.23 demonstrates a spontaneous breath from a baby

not receiving any ventilatory support. It has been included to
demonstrate differences between spontaneous and assisted
breathing. Note the much more rounded contour and return
to baseline.
a 2
1
Flow (L/min)
0
2 4 6 8 10 12
–1
–2
Figure 2.23 Spontaneous breathing (a, schematic; b, actual). The

baby is not receiving any ventilatory support. The breaths show sig-
nificant variability
Suggested Reading
Becker MA, Donn SM. Real-time pulmonary graphic monitoring.
Clin Perinatol. 2007;34:1–17.
Bhutani VK, Benitz WE. Pulmonary function and graphics. In:
Goldsmith J, Karotkin E, editors. Assisted ventilation of the new-
born. 5th ed. Philadelphia: Saunders; 2011. p. 306–20.
Chapter 3
Impact of Mechanical
Ventilation on Waveforms
3.1 Introduction
The interaction of mechanical ventilation and pulmonary
mechanics is easier to appreciate by waveform monitoring.
This enables the clinician to more objectively assess patient-
ventilator synchrony and to adjust ventilator parameters to
the individual needs of the baby based on both the underly-
ing pathophysiology and the baby’s response to changes in
ventilator settings.
3.2 Ventilator Modes

The ventilator mode refers to the sequencing or pattern of
mechanical breaths delivered to the patient. There are essen-
tially four modes of ventilation used in neonatal intensive
care: intermittent mandatory ventilation (IMV), synchro-
nized intermittent mandatory ventilation (SIMV), assist/
control ventilation (A/C), and pressure support ventilation
(PSV). Within these modes, different breath types or combi-
nation of breath types may be used without changing their
definitions, and analysis of waveforms may be necessary to
distinguish these.

46 Chapter 3. Impact of Mechanical Ventilation on Waveforms
3.2.1 IMV
IMV was the first interactive mode, allowing the patient to

breathe fresh gas via the bias flow in the ventilator circuit
supported by positive end-expiratory pressure (PEEP) cir-
cuit between mandatory breaths. During IMV, mechanical
breaths are delivered to the patient at fixed intervals deter-
mined by setting a fixed respiratory rate. For example, if a
clinician chooses a rate of 30 breaths/min, a mechanical
breath will be delivered every 2 s, regardless of where the
baby is in his or her own spontaneous cycle. Thus, asynchrony
is a major drawback, because the baby may be trying to
exhale against incoming inspiratory pressure, resulting in a
small tidal volume (Vt), or to inhale with incoming positive
pressure, resulting in a larger Vt. Asynchrony can lead to inef-
ficient gas exchange, increase the risk of air leak, or require
more sedation (prolonging the time on mechanical ventila-
tion); irregularities in cerebral blood flow velocity and
increased intraventricular hemorrhage have also been
described.
Figure 3.1 displays flow and pressure volume waveforms
during IMV. The ventilator rate has been set to deliver 30
breaths/min. Note that a mechanical breath is regularly deliv-
ered every 2 s. In between the mechanical breaths, the baby
may breathe spontaneously, but these breaths are supported
only by the applied PEEP.
3.2 Ventilator Modes 47
a 5
V
0
–5
0.00 sec 2 4 6 8 10
25
Paw
–10
6/15/99 06:43
Figure 3.1 Flow and pressure waveforms during IMV (a, schematic;
b, actual). Mechanical breaths are provided every 2 s; in between, the
patient may breathe spontaneously, supported only by PEEP
Figure 3.2 represents the effects of asynchrony. Variability

in Vt delivery can be seen, even when the peak inspiratory
pressure (PIP) is held constant. Thus when the baby is
breathing with the ventilator, the Vt is higher than when the
baby is breathing against the ventilator.
a 15
V
0
–15
0.00 sec 2 4 6 8 10
45
VT
0
–15
Figure 3.2 Dyssynchronous breathing during IMV (a, schematic;

b, actual). The flow and volume waveforms demonstrate variability
in delivered volume. The large volume breath occurred when the
baby and the ventilator randomly synchronized
3.2.1.1 Patient-Triggered Ventilation
Patient-triggered ventilation (PTV) refers to modes of ventila-

tion in which the patient’s own spontaneous effort may be used
to trigger the initiation of a mechanical breath that is better syn-
chronized than an IMV breath. Some measure of spontaneous
breathing is used as a marker of patient effort. In newborns this
is most commonly a change in airway flow or pressure and, more
recently, diaphragmatic activity. The assist sensitivity is an adjust-
able trigger. It should be set low enough to enable the baby to
easily exceed it, but not too low that leaks or non-respiratory
flow changes induce auto-cycling (see Fig. 2.18). PTV has become
more widespread since improvements in microprocessor and
sensor technology have reduced trigger delay (system response
time). This is the interval between reaching the assist sensitivity
threshold and the rise in airway pressure at the proximal airway.
3.2.2 SIMV
SIMV was developed to help reduce some of the asynchrony

that plagues IMV. A trigger signal is used initiate a mechanical
breath in close temporal proximity to a spontaneous breath. As
with IMV, the clinician selects the mechanical ventilator rate,
but the ventilator may not cycle at exactly this interval. There
is a “timing window” that extends for several milliseconds
before or after the set interval. If the patient initiates a sponta-
neous breath within the timing window, the onset of the
mechanical breath will be synchronized to it. If the patient fails
to breathe spontaneously or cannot reach the trigger threshold
within the timing window, a mechanical breath will be pro-
vided. As with IMV, spontaneous breathing between mechani-
cal breaths is supported solely by PEEP, often resulting in two
populations of breaths- assisted breaths, with relatively higher
Vt, and unassisted breaths, with low Vt. Breaths may be either
time-cycled or flow-cycled (see Figs. 2.15 and 2.16).
Figure 3.3 displays the use of SIMV. Breaths that are
patient-triggered (the baby has created a flow change above
the assist sensitivity [trigger] threshold) have a yellow inspi-
ratory waveform. Breaths that are machine-initiated would
have a red inspiratory waveform (none are shown).
a Paw (cmH2O) 20
10
0
2 4 6 8 10
–10
2
Flow (L/min)
1
0
2 4 6 8 10
–1
–2
4
Vt (mL)
0
2 4 6 8 10
–2
Figure 3.3 SIMV (a, schematic; b, actual). The ventilator is set at 35

breaths per minute or one breath every 1.7 s. If the baby initiates a
spontaneous breath within the timing window, a mechanical breath
will be synchronized to it. If the baby fails to breathe within this
time, a mandatory breath will be given. In between, spontaneous
breaths are supported with PEEP
3.2.3 Assist/Control (A/C)
A/C is a mode of ventilation in which every spontaneous

breath that exceeds the assist sensitivity threshold initiates a
mechanical breath (assist). The clinician sets a ventilator (con-
trol) rate, which acts as back-up ventilation in the event that
the patient fails to exhibit sufficient effort within the allotted
time. For example, if the control rate is set at 30 breaths/min,
the baby has 2 s to initiate a breath before a mechanical breath
will be automatically provided. Each time the baby breathes,
the clock is reset. The baby may initiate as many breaths as she
or he wants within the interval, and each is supported by the
peak pressure (Fig. 3.4a, schematic; b, actual) or delivered
a Paw (cmH2O) 20
10
0
2 4 6 8 10 12
–10
2
Flow (L/min)
1
0
2 4 6 8 10 12
–1
–2
4
Vt (mL)
0
2 4 6 8 10 12
–2
Figure 3.4 Pressure-targeted A/C ventilation (a, schematic; b, actual).

In this mode, each time the patient takes a breath that exceeds the
flow trigger assist sensitivity, a synchronized pressure-targeted breath
is provided (shown in yellow). If the baby does not breathe above the
control rate, or if spontaneous breaths fail to meet the trigger thresh-
old, a mandatory (control) breath is provided (shown in red). Note
that not all of the spontaneous breaths reach the trigger threshold and
those that do not fail to result in the delivery of a mechanical breath
(arrows)
volume (Fig. 3.5; a, schematic; b, actual)), as well as the PEEP,

chosen by the clinician. Pressure targeted A/C may also be
time-cycled or flow-cycled. If flow-cycling is chosen, both the
initiation and the termination of the breath will be controlled
by the patient, achieving the best possible degree of synchroni-
zation between the baby and the ventilator.
a Paw (cmH2O) 40
20
0
2 4 6 8 10
–20
6
Flow (L/min)
3
0
2 4 6 8 10
–3
–6
30
20
Vt (mL)
10
0
2 4 6 8 10
–10
Figure 3.5 Volume-targeted A/C ventilation (a, schematic; b,

actual). Similar to pressure-targeted A/C, triggering results in the
delivery of a volume-targeted breath. Control breaths are provided
if the baby fails to meet the triggering threshold or fails to breathe
in the allotted time
3.2.4 PSV
One of the major limitations of SIMV is the lack of sufficient

support for spontaneous breathing between mechanical
breaths. The use of mechanical ventilation creates additional
work of breathing for the baby as a consequence of narrow
lumen endotracheal tubes, increased dead-space, and effort
to trigger the ventilator or open a demand valve. Collectively,
this is referred to as the imposed work of breathing. If the
support provided to spontaneous breaths is inadequate, it
may prolong the infant’s ventilator course and increase respi-
ratory morbidity.
PSV was developed specifically to overcome the imposed
work of breathing by supporting spontaneous breaths during
mechanical ventilation. It is an inspiratory pressure “boost.” It
is usually used in conjunction with SIMV, but it may be used
alone in babies with reliable respiratory effort. It is a form of
PTV, in that spontaneous breaths that meet or exceed the trig-
ger threshold result in the delivery of additional inspiratory
pressure to help unload respiratory musculature. PSV breaths
are thus patient-triggered, pressure-limited, and typically flow-
cycled with an inspiratory time (Ti) limit. When the amount of
pressure is adjusted to provide a full Vt breath, it is referred to
as PSmax. The lowest pressure, used to merely overcome the
imposed work of breathing, is referred to as PSmin. Breaths may
thus be fully (PSmax) or partially supported at some lower level.
The effect of fully supported spontaneous breathing
(PSmax) is shown in Fig. 3.6 . Note that the Vt is the same for
both the SIMV breaths and the PSV breaths. In contrast,
a Paw (cmH2O) 20
10
0
1 2 3 4 5 6
–10
6
Flow (L/min)
3
0
1 2 3 4 5 6
–3
–6
30
20
Vt (mL)
10
0
1 2 3 4 5 6
–10
Figure 3.6 Pressure support ventilation (a, schematic; b, actual).

Spontaneous breaths that meet the trigger threshold are supported
by an inspiratory pressure assist. Pressure support is usually used in
conjunction with SIMV to support spontaneous breathing. Here,
PSV is used alone to fully support spontaneous breaths
Fig. 3.7 displays the effect of partially supported breathing.

Note that the Vt delivery during PSV is less than during the
mechanical breaths delivered by SIMV. Some devices offer a
similar mode, called volume support, that utilizes volume
targeting with automatic pressure adjustment.
40
a Paw (cmH2O)
20
0
2 4 6 8 10 12
–20
SIMV PSV
6
Flow (L/min)
3
0
2 4 6 8 10 12
–3
–6
30
20
Vt (mL)
10
0
2 4 6 8 10 12
–10
Figure 3.7 Pressure support ventilation (a, schematic; b, actual).

Spontaneous breaths (PSV) are only partially supported and pro-
vide a lower tidal volume than the SIMV breaths (SIMV) (Used
with permission from Fanaroff and Martin’s Neonatal-Perinatal
Medicine, edn 10, Martin et al., editors, Copyright Elsevier, 2015.)
3.3 Techniques to Alter Mean Airway

Pressure
One of the key principles of mechanical ventilation is that
oxygenation is proportional to mean airway pressure. Mean
airway pressure recruits lung volume, exposes more alveolar
surface area to gas exchange, and helps to optimize the
matching of ventilation and perfusion. Ventilation, con-
versely, is the product of Vt and frequency. The major deter-
minants of Vt are the difference between the peak (PIP) and
the baseline (PEEP) pressures, or amplitude.
There are four main determinants of mean airway pres-
sure: PIP, PEEP, the Ti, and to a lesser extent, the ventilator
rate (by increasing the number of cycles in the same time
period, the average pressure will increase).
Waveforms are an objective means to both understanding
how these parameters affect mean airway pressure and how
the patient responds to changes. Figure 3.8 is a schematic
diagram indicating how changes in PIP, PEEP, and Ti will alter
the shape of the pressure waveform. Remember that the
mean airway pressure is represented by the area under the
curve (AUC), and thus adjustments that increase the AUC
will increase the mean airway pressure and should improve
oxygenation as long as lung volume is not too high; increasing
3.3 Techniques to Alter Mean Airway Pressure 61
Pressure
A C
E
D
Time
Figure 3.8 Schematic diagram to demonstrate ways to increase

mean airway pressure. Rise time can be adjusted to increase the rate
of inspiratory flow (A). Peak inspiratory pressure can be increased
(B). The inspiratory time can be lengthened (C). PEEP can be
increased (D). The expiratory time can be shortened (E) or the rate
increased to provide more area under the curve per unit of time
(Used with permission from Fanaroff and Martin’s Neonatal-Perinatal
Medicine, edn 10, Martin et al., editors, Copyright Elsevier, 2015)
mean airway pressure in the already over-distended lung

causes gas exchange to worsen and increases the risk of air
leak. Increasing the PIP will add additional AUC by raising
the upper limit of the pressure waveform. Increasing the
PEEP will raise the baseline and increase the AUC during
expiration. Increasing the Ti will horizontally expand the
AUC during inspiration. Each of these is shown subsequently.
Figure 3.9 represents pressure, flow, and volume waveforms
during the initial ventilator settings (PIP 20 cm H2O, PEEP
4 cm H2O, Ti 0.35 s, and rate 30 breaths/min). The modality is
pressure control, where flow is variable. The peak pressure
represents the sum of the inspiratory pressure (16 cm H2O)
and the PEEP (4 cm H2O).
a Paw (cmH2O) 40
P = 20/4 TI = 0.35 Rate = 20
20
0
2 4 6 8 10 12
–20
10
Flow (L/min)
5
0
2 4 6 8 10 12
–5
–10
30
20
Vt (mL)
10
0
2 4 6 8 10 12
–10
Figure 3.9 Baseline waveforms (a, schematic; b, actual). Starting

settings of PIP 20 cm H2O, PEEP 4 cm H2O, Ti 0.35 s, and rate
30 bpm
3.3.1 Change in PIP
Figure 3.10 shows the effects of increasing the PIP by 10 cm

H2O to 30 cm H2O. Note the sharp increase in the peak
pressure and the AUC. This resulted in an increase in mean
airway pressure as well as a 50 % increase in Vt.
a 40
P = 30/4 TI = 0.35 Rate = 30
Paw (cmH2O)
20
0
2 4 6 8 10 12
–20
10
Flow (L/min)
5
0
2 4 6 8 10 12
–5
–10
30
20
Vt (mL)
10
0
2 4 6 8 10 12
–10
Figure 3.10 Effect of raising the PIP by 10 cm H2O (a, schematic;

b, actual). Note changes in pressure and volume compared to
Fig. 3.9
3.3.2 Change in PEEP
In Fig. 3.11, the PEEP was increased to 8 cm H2O, while all

other parameters were held constant. Observe the change in
the position of the baseline and how it has contributed to the
increase in AUC. Also note that the amplitude (PIP-PEEP),
the major determinant of Vt, has decreased, and the Vt has
fallen from 9.9 to 7.9 mL/kg.
a Paw (cmH2O) 40
P = 30/8 TI = 0.35 Rate = 30
20
0
2 4 6 8 10 12
–20
10
Flow (L/min)
5
0
2 4 6 8 10 12
–5
–10
30
20
Vt (mL)
10
0
2 4 6 8 10 12
–10
Figure 3.11 Effect of raising the PEEP by 4 cm H2O (a, schematic;

b, actual). This resulted in a decrease in the amplitude (PIP-PEEP),
though PIP remains at 30, delivered Vt has fallen, compared to
Fig. 3.10
In Fig. 3.12, the PEEP was lowered to 2 cm H2O, while

maintaining the PIP at 20 cm H2O, as it was in Fig. 3.10. Note
the downward shift in the baseline and the decreased AUC
during the expiratory phase. Vt delivery increased from 6.6 to
7.9 mL/kg as a consequence of the increased amplitude.
a Paw (cmH2O) 40
P = 20/2 TI = 0.35 Rate = 30

20
0
2 4 6 8 10 12
–20
10
Flow (L/min)
5
0
2 4 6 8 10 12
–5
–10
30
20
Vt (mL)
10
0
2 4 6 8 10 12
–10
Figure 3.12 Effect of decreasing PEEP to 2 cm H2O from settings

shown in Fig. 3.9 (a, schematic; b, actual). This increased the ampli-
tude while lowering the mean airway pressure, because of the
increase in amplitude, tidal volume also increases
3.3.3 Change in Ti
Prolonging the Ti can have a marked impact on the pressure

waveform. In the example shown in Fig. 3.13, the Ti was
increased from 0.35 to 0.7 s. Note how it has horizontally
increased the AUC. The Vt has increased from 7.9 to 8.9 mL/
kg as well.
a Paw (cmH2O) 40
P = 30/6 TI = 0.70 Rate = 30
20
0
2 4 6 8 10 12
–20
10
Flow (L/min)
5
0
2 4 6 8 10 12
–5
–10
30
20
Vt (mL)
10
0
2 4 6 8 10 12
–10
Figure 3.13 Effect of prolonging the inspiratory time from 0.35 to

0.7 s (a, schematic; b, actual). The area under the curve has increased
indicating a higher mean airway pressure. In addition, compared to
Fig. 3.11, the delivered volume is higher, though PIP and PEEP are
unchanged
3.3.4 Change in Rate
In Fig. 3.14, the ventilator rate was increased from 30 to 40

breaths/min.
Although there is no observable difference in any of the
individual waveforms, there are more of them per unit of
time, so that the cumulative AUC per minute will increase, in
this case, by 33 %.
a Paw (cmH2O) 40 P = 30/6 T1 = 0.70 Rate = 40
20
0
2 4 6 8 10 12
–20
10
Flow (L/min)
5
0
2 4 6 8 10 12
–5
–10
30
20
Vt (mL)
10
0
2 4 6 8 10 12
–10
Figure 3.14 Effect of increasing the ventilator rate from 30 to

40 bpm (a, schematic; b, actual). More cycles per second results in a
higher mean airway pressure, although the effect is more pro-
nounced on ventilation than oxygenation
Suggested Reading
Keszler M. State of the art in conventional mechanical ventilation.
J Perinatol. 2009;29:262–75.
Mrozek JD, Bendel-Stenzel EM, Meyers PA, Bing DR, Connett JE,
Mammel MC. Randomized controlled trial of volume-targeted
synchronized ventilation and conventional intermittent manda-
tory ventilation following initial exogenous surfactant therapy.
Pediatr Pulmonol. 2000;29:11–8.
Schulke SM, Pillow J, Ewald B, Patole SK. Flow-cycled versus time
cycled synchronized ventilation for neonates. Cochrane Database
Syst Rev. 2010;7:CD008246.
Chapter 4
Pulmonary Mechanics
and Loops
4.1 Introduction
Whereas pulmonary waveforms are time-based and relate
changes in pressure, flow, and volume to time, these parame-
ters may also be presented relative to each other. These are
commonly referred to as loops. The two most frequently used
in clinical practice are the pressure-volume (P-V) loop and
the flow-volume (F-V) loop. The interpretation of these loops
can provide valuable information about the mechanical prop-
erties of the lung, how it is “performing” on a breath-to-
breath basis, and how it responds to changes in pathophysiology,
mechanical ventilation, and their inter-relationship.
Interpretation of pulmonary loops involves a degree of
pattern recognition. Unfortunately, the shapes of both P-V
and F-V loops can be distorted if the axes are improperly
scaled. Not every device automatically adjusts the axes, so
care must be taken by the clinician to do so. Axes should
completely contain the limits of the loop and should be as
close to 1:1 as possible. Another problem is the lack of con-
vention among device manufacturers in the way in which the
F-V loop is drawn. Most use a clockwise direction, but some
use a counterclockwise direction, so clinicians need to be
aware of this and to properly orient themselves to the loop’s
direction.

76 Chapter 4 Pulmonary Mechanics and Loops
4.2 The P-V Loop

The P-V loop displays the relationship of pressure and vol-
ume during a single breath. Pressure is displayed on the
x-axis and volume is displayed on the y-axis. The anatomy of
a P-V loop is shown in Fig. 4.1. Note that the origin of the
loop does not start at the origin of the graph because of the
application of positive end-expiratory pressure (PEEP). As
inspiration begins, there is a rise in pressure and subsequently
volume. This describes the inflation limb of the loop and ter-
minates at the peak inspiratory pressure (PIP). As the lung
deflates, pressure and volume decrease, and the deflation
limb terminates at zero volume and the PEEP level.
The P-V loop provides valuable information about lung
mechanics. The dotted line is the compliance axis, a measure of
the stiffness or elasticity of the lung. Compliance is defined as
the change in volume divided by the change in pressure. Thus,
if a 1 cm H2O increase in pressure results in a 1 mL increase in
lung volume, the axis will be 45°. As compliance decreases, the
axis will shift downward and to the right. Conversely, as com-
pliance improves, the axis will shift upward and to the left.
The work of breathing can be qualitatively estimated by
the P-V loop. It is the area bounded by the inflation limb and
a horizontal line connecting the PIP with the y-axis. As the
compliance decreases and the loop shifts downward and to
the right, this area increases and more pressure must be
applied to achieve the same lung volume.
This loop also provides information about resistance. A
line drawn from the midpoint of the inflation limb to the
compliance axis is a measure of inspiratory resistance; a line
drawn from the midpoint of the deflation limb to the compli-
ance axis is a measure of expiratory resistance. Hysteresis is a
term that is used to describe the difference between the infla-
tion and the deflation limbs and is determined by the elastic
properties of the lung. Under normal circumstances, the
shape of the P-V loop is oval, resembling a football. Hysteresis
thus represents the resistive work of breathing.
Finally, inflection points may be seen in both the inflation
and the deflation limbs anywhere that the slope of these
change. These are described in detail later.
4.2 The P-V Loop 77
Figure 4.1 The pressure-volume (P-V) loop (a, schematic; b,

actual). Changes in pressure and volume during a single breath are
shown. The dotted line on the schematic represents the compliance
axis. This graphic enables inferences about compliance, resistance,
and lung inflation (Used with permission from Fanaroff and
Martin’s Neonatal-Perinatal Medicine, edn 10, Martin R et al.,
editors, Copyright Elsevier, 2015)
4.2.1 Decreased Compliance
Decreased compliance is encountered frequently in neonatal

practice. It may be seen in respiratory distress syndrome
(RDS), pulmonary edema, pneumonia, or other conditions
marked by surfactant inactivation or depletion. When com-
pliance is low, the lung is stiff, requiring more pressure to
deliver the same tidal volume (Vt) compared to normal
compliance.
The relationship of pressure and volume help us to under-
stand differences in the way mechanical ventilatory targets
work. Figure 4.2 shows the changes in Vt delivery during
pressure-targeted ventilation. Both breaths were delivered at
the same pressure but at different compliance. The upper
loop has a compliance axis of about 45° (compliance = 1.0 mL/
cm H2O), whereas the lower loop has a compliance of about
30° (compliance = 0.67 mL/cm H2O). Because pressure is held
constant, the delivered volume is considerably less at lower
compliance.
4.2 The P-V Loop 79
a b
15
10
Vt (mL)
458
–10 0 10 20
Paw (cmH2O)
15
10
Vt (mL)
5
308
–10 0 10 20
Paw (cmH2O)
Figure 4.2 P-V loops demonstrating changes in compliance during

pressure-targeted ventilation (a, schematic; b, actual). The P-V loop
on the bottom demonstrates poor lung compliance. The compliance
axis is only 30°. The top loop demonstrates improved compliance.
Note that the compliance axis is 45°. Because pressure is constant, a
larger tidal volume is delivered at better compliance (Used with
permission from Fanaroff and Martin’s Neonatal-Perinatal Medicine,
edn 10, Matin et al., editors, Copyright Elsevier, 2015)
In volume-targeted ventilation, the ventilator will main-

tain volume delivery by allowing pressure to fluctuate.
Figure 4.3 schematically demonstrates this difference.
Pressure targeting is on the left, volume targeting on the
right. With pressure targeting, volume delivery depends pri-
marily on lung compliance. The lower loop demonstrates
poor compliance. When compliance improves (upper loop),
delivered volume increases, even though pressure is constant.
With volume targeting, volume delivery is constant, and pres-
sure is varied. As shown, the loop on the right demonstrates
volume delivery at lower compliance. When compliance
improves (smaller loop on the left), pressure is automatically
decreased to maintain consistent volume delivery. These
changes will also occur in the reverse situation. If compliance
suddenly decreases, volume delivery will decrease during
pressure targeting, and pressure will increase during volume
targeting.
The converse process during volume-targeted ventilation
is known as auto-weaning. As compliance improves, the pres-
sure is automatically decreased to maintain constant volume
delivery (Fig. 4.4). In pressure-targeted ventilation, improv-
ing compliance will lead to larger volume delivery unless the
clinician is vigilant and decreases the inspiratory pressure.
4.2 The P-V Loop 81
Pressure targeted Volume targeted

Volume
Volume
Pressure Pressure
Figure 4.3 Schematic diagram demonstrating the differences

between pressure and volume targeting when lung compliance
changes. See text for explanation
Figure 4.4 Graphic trend screen during volume targeted ventila-

tion. Note the reduction in peak inspiratory pressure over time. The
increase in tidal volume resulted from less compressible volume loss
as compliance improved
4.2.2 Lung Inflation
The advent of real-time graphics has greatly contributed to

our understanding of lung inflation and can enhance the
safety of mechanical ventilation. In the past information
about lung inflation was limited to the occasional chest radio-
graph, observation of chest excursions, and auscultation of
breath sounds, which are all crude measures.
4.2.3 Hyperinflation
Figure 4.5 is a schematic representation of the P-V relation-

ship. Note that the inflation limb is not linear over the entire
range. However, the compliance axis (slope of ΔV/ΔP) is
linear over the normal range of Vt around the functional
residual capacity (FRC) of the lung. Over this linear range, Vt
will increase proportionally to lung compliance (ΔV = C ×
ΔP). Lung compliance and the P-V relationships are deter-
mined by the interaction of the elastance of the lung and
alveolar surface tension. As the lung approaches maximum
4.2 The P-V Loop 83
Figure 4.5 Schematic representation of the P-V relationship dem-

onstrating the concept of upper and lower inflection points and the
C20/C concept. See text
filling and tissue distensibility becomes more limited, the

compliance will decrease, resulting in less volume gain per
unit of incremental pressure, and the slope of the compliance
axis will shift downward. This creates an upper inflection
point on the P-V inflation limb and graphically creates a
“penguin beak” or “duck bill” appearance to the loop. This
pattern is indicative of hyperinflation, and it can be quanti-
fied by using a metric known as the C20/C ratio (Fisher, 1988).
The C20/C ratio examines the slope of the last 20 % of the
inflation limb and compares it with the linear portion of the
curve. If the curve remained linear to the peak pressure, the
ratio would remain at 1.0; if the loop begins to bend to the
right, the slope will decrease and the ratio will decrease to
<1.0. Most present-day ventilators have the capability to dis-
play this measurement.
Figure 4.6 demonstrates hyperinflation and the use of the
C20/C ratio to quantify it.
4.2 The P-V Loop 85
a 2
Vt (mL)
0
2 4 6
–1
–2
Flow (L/min)
4
Paw (cmH2O)
–20 0 20 40
Vt (mL)
Figure 4.6 Hyperinflation (a, schematic; b, actual). Note the C20/C

of only 0.82
4.2.4 Underinflation
Examination of the P-V loop can also provide information

about a lung that is inadequately inflated. Lung inflation
below the FRC will also produce a slope that is less than the
linear portion of the compliance axis, as seen in Fig. 4.5. Note
that little volume is being delivered at the lower end of the
inflation limb until the opening pressure has been exceeded
and volume starts to increase, creating a lower inflection point
in the loop.
Adjustments in PEEP and PIP (or delivered Vt in volume-
targeted ventilation) can improve lung mechanics and nor-
malize the P-V loop. Figure 4.7 displays a P-V loop in which
the PEEP has been set below the lower inflection point. It
has created a very abnormal appearance, such that the loop
4.2 The P-V Loop 87
a 30
20
10
–20 0 20 40
A B
Figure 4.7 Underinflation (a, schematic; b, actual). The PEEP (A)

has been set below the lower inflection point (B) resulting in abnor-
mal inflation. Note how little volume is delivered as pressure is
increased during inspiration
looks more like a box than a football. Applied pressure does

not deliver any effective volume for much of the inspiratory
phase. Similarly, during deflation the lung rapidly de-recruits
when the critical closing pressure is reached. Increases in
PEEP above the lower inflection point and a concomitant
increase in PIP have been applied in Fig. 4.8, normalizing the
shape of the loop and improving both volume delivery and
compliance.
4.2 The P-V Loop 89
a 30
20
10
–20 0 20 40
A
Figure 4.8 Normal inflation (a, schematic; b, actual). The PEEP has
been increased above the lower inflection point, resulting in a
marked improvement in the inflation of the lung and better pulmo-
nary mechanics
4.2.5 Pressure Overshoot
Ventilator modalities that use variable inspiratory flow, such

as pressure control and pressure support, may produce flow
rates that exceed the mechanical properties of the lung and
lead to hyperinflation. This is depicted in Fig. 4.9. The infla-
tion limb of the P-V curve shows a bulge or a notch, and
the pressure waveform (Fig. 4.10) shows a double peak at
PIP. The flow rate may be modulated by a feature known as
rise time, available on most devices, which allows a qualitative
adjustment in the flow rate. In Figs. 4.11 and 4.12, the rise
time has been adjusted and the graphics have normalized.
This is also shown as a composite in Fig. 4.12c, d.
4.2 The P-V Loop 91
35 –150
a
32 –10
–10 30
–10 150
Figure 4.9 Pressure overshoot (a, schematic; b, actual). The inspira-

tory flow rate is too high, resulting in “notching” of both the P-V
and F-V loops (arrows)
a V 0.0 1pm 10
–10
0.00 sec 1 2 3 4 5
30
Paw 3.75 cmH2O
–10
Figure 4.10 Pressure overshoot (a, schematic; b, actual). The flow

waveform shows a smaller, second peak at end inspiration, and the
pressure waveform shows a notch at the peak (arrows)
4.2 The P-V Loop 93
a Paw (cmH2O) 20
10 26.4
0
2 4 6 8 10 12
–10
PIFR at higher rise time
10
Flow (L/min)
5 8.9
0
2 4 6 8 10 12
–5
–10
30
16.8
20
Vt (mL)
10
0
2 4 6 8 10 12
–10
Figure 4.11 Effect of rise time on pressure overshoot (a, schematic;

b, actual). A high rise time (higher inspiratory flow rate) results in a
peak pressure of 26.4 cm H2O, peak inspiratory flow rate of 8.9
LPM, and a tidal volume of 16.8 mL
a Paw (cmH2O)
20
22.9
10
0
2 4 6 8 10 12
–10
PIFR at lower rise time
10
Flow (L/min)
5 8.3
0
2 4 6 8 10 12
–5
–10
30
14.6
20
Vt (mL)
10
0
2 4 6 8 10 12
–10
Figure 4.12
4.2 The P-V Loop 95
c 10 A
5 B
0
20 40 60
–5
–10
60
A
40
B
20
–20 0 20 40
Figure 4.12 Decreasing the rise time (while keeping all other
parameters the same) decreased the peak pressure to 22.9 cm H2O,
the peak inspiratory flow rate to 8.3 LPM, and the tidal volume to
14.6 mL (a, schematic; b, actual). These changes can also be seen on
the loops (c, schematic; d, actual). The higher rise time is seen in
loops labeled A, the lower rise time in loops labeled B
4.2.6 Air Hunger
If the delivered Vt is inadequate to meet the patient’s need,

air hunger may develop. In this situation the baby may be
noted to be “pulling” or displaying increased work of breath-
ing. This creates a distinctive pattern on the P-V loop, with a
“figure of eight” reversal of the inflation and deflation limbs
at the top of the loop, shown in Fig. 4.13. This can be corrected
by providing additional flow, volume, or inspiratory time,
depending on the clinical situation.
4.2 The P-V Loop 97
a 15
10
–20 0 20 40
Figure 4.13 Air hunger (a, schematic; b, actual). Note the “figure of
eight” appearance at the top of the P-V loop (arrow)
4.2.7 Increased Inspiratory Resistance
As stated earlier, the hysteresis of the P-V loop represents

the resistive work of breathing. Excessive distance between
the inflation limb and the compliance axis represents
increased inspiratory resistance, as shown in Fig. 4.14 . This
pattern can often be corrected by increasing inspiratory flow,
inspiratory time, or PEEP.
4.2 The P-V Loop 99
a 6
Restricted flow
3
0
5 10 15
–3
–6
Figure 4.14 Inspiratory flow restriction (a, schematic; b, actual). The

inspiratory flow limb has a flattened appearance because of the lin-
earity of the flow rate from increased resistance during inspiration
4.2.8 Increased Expiratory Resistance
Increased expiratory resistance, conversely, produces changes

in the deflation limb of the P-V loop, in which it may be sepa-
rated or bowed from the compliance axis. This is shown in
Fig. 4.15. Adjustments to correct this might include increases
in expiratory time and/or PEEP. This may also represent a
developing ball-valve endotracheal tube obstruction.
4.2 The P-V Loop 101
a 60
40
20 A
–20 0 20 40
Figure 4.15 Increased expiratory resistance (a, schematic; b, actual).

The abnormal shape of the P-V loop results from increased expira-
tory resistance. Note the distance from the compliance axis (A) to
the deflationary limb (arrow)
4.2.9 Surfactant Administration
The administration of exogenous surfactant to a newborn

with RDS will lower alveolar surface tension and improve
pulmonary compliance. Because this can happen rapidly,
there is a risk of overdistension of the lung if pressure is not
reduced rapidly enough.
Figure 4.16 represents the P-V loop of a baby with RDS,
prior to surfactant administration. Note the poor compliance
and the amount of pressure required to deliver the Vt.
a 10
60
5
40
Vt
0
20 40 60
20 A
C
–5
–10 –20 0 20 B 40
Figure 4.16 Loops prior to surfactant administration (a, schematic;

b, actual). Note poor compliance (A); at peak inspiratory pressure
(B) of about 35 cm H2O, tidal volume (C) is only 18 mL
Figure 4.17 shows the changes almost immediately after

the administration of surfactant. The compliance has
improved dramatically, and at the same pressure, consider-
ably more Vt is being delivered to the baby. Weaning the PIP
is indicated.
a 10
60
5
40
Vt A
C
0
20 40 60
20
–5
–10 –20 0 20 B 40
Figure 4.17 Loops following surfactant administration (a, sche-

matic; b, actual). Note dramatic improvement in compliance (A). At
the same pressure (B), tidal volume delivery (right) is now 30 mL
4.2.10 Excessive Inspiratory Hold
Some mechanical ventilators contain an inspiratory hold

function. This is used during volume-targeted ventilation to
prolong the inspiratory time, which may otherwise be too
short at higher inspiratory flows. If the inspiratory hold is too
long, however, it will distort the upper portion of the P-V
loop, causing it to “balloon” as shown in Fig. 4.18. This may
a 6
7.5
Vt (mL)
–20 0 20 40
Paw (cmH2O)
Figure 4.18 Excessive inspiratory hold (a and c, schematic; b and d,

actual). On the P-V loop, note the “ballooning” at the top of the grey
loop at end inspiration (arrow). This was adjusted to normalize infla-
tion in the red and blue loop. On the flow waveform, note the pro-
longed zero flow state (arrows) before the start of the expiratory phase
also be seen in the flow waveform (Fig. 4.18c). Note the pro-
longed time at the zero flow state at end inspiration. If this
occurs, the inspiratory hold should be shortened.
c Paw (cmH2O) 40
20
0
2 4 6 8 10 12
–20
6
Flow (L/min)
3
0
2 4 6 8 10 12
–3
–6
60
40
Vt (mL)
20
0
2 4 6 8 10 12
–20
Figure 4.18 (continued)

4.3 The F-V Loop

The F-V loop describes the pattern of airflow during tidal
breathing. Volume is shown on the x-axis and flow is shown
on the y-axis. Like the flow waveform, inspiratory and expira-
tory flows are in opposite directions. Because the F-V loop
has not yet been standardized, the clinician needs to deter-
mine whether inspiratory flow is displayed above or below
zero flow and, thus, the direction in which the loop is being
drawn. We display a clockwise F-V loop.
The anatomy of the F-V loop is shown in Fig. 4.19. Inspiration
begins at the origin of the graph (zero flow) and increases until
it reaches the peak inspiratory flow rate (PIFR). This corre-
sponds to the accelerating inspiratory flow seen on the flow
waveform. Flow then decelerates (as in the waveform), and
reaches the zero flow state at the point where it crosses the
volume axis, representing the delivered Vt. Expiratory flow
begins with the accelerating phase, reaches the peak expiratory
flow rate (PEFR), then decelerates until it returns to the origin
and another zero flow state at end expiration. The general
shape of the loop should be round or ovoid and the two halves
(inspiratory and expiratory) should be close to mirror images.
However, during a controlled breath, as a consequence of
either pharmacological paralysis or lack of patient interaction
with the ventilator, the expiratory limb will show a rapid
attainment of peak flow followed by a linear decrease in flow
and volume, with a loss of the ovoid shape.
The F-V loop thus describes the relationship of volume
and flow. Because flow is the time rate of volume delivery, if
there is high resistance to flow, there will be lower flow for a
given volume of gas, that is, it will take longer to move the
same volume of gas when resistance is high.
4.3 The F-V Loop 111
Figure 4.19 The flow-volume (F-V) loop (a, schematic; b, actual).

Note the key features- peak inspiratory and expiratory flow rates,
and tidal volume, where the loop crosses the x-axis at the end of
inspiration. Because devices may draw this loop clockwise or
counter-clockwise, clinicians must determine the inspiratory and
expiratory components
4.3.1 Elevated Inspiratory Resistance
Abnormalities in the inspiratory portion of the F-V loop can

be seen with elevated inspiratory resistance. This gives the
appearance of an inspiratory flow restriction, with decreased
PIFR and flattening of the loop (Fig. 4.20).
a 6
3
Vt (mL) - Flow (L/min)
0
5 10 15
–3
–6
Figure 4.20 F-V loop (a, schematic; b, actual) demonstrating

increased inspiratory resistance. Rather than having an oval or
circular appearance with a discernible peak inspiratory flow rate,
the loop is flat across most of the inspiratory phase (arrow). This
suggests an extrathorcic obstruction
4.3.2 Elevated Expiratory Resistance
Abnormalities in the expiratory portion of the F-V loop can

be seen with elevated expiratory resistance. Again there is a
reduction in the PEFR and abnormalities in the shape of the
loop. Figure 4.21 demonstrates the pattern seen with obstruc-
tive airway disease, in which the abnormality occurs primarily
during the decelerating phase.
a 10
5
0
20 40 60
–5
–10
Figure 4.21 F-V loop (a, schematic; b, actual) demonstrating

increased expiratory resistance. Rather than having an ovular or
circular appearance, the loop looks compressed (arrow)
4.3.3 Fixed Airway Obstruction
In the presence of a fixed airway obstruction, both inspira-

tory and expiratory resistances may be elevated, resulting in
a “compression” of the F-V loop with lower PIFR and
PEFR. This is shown in Fig 4.22.
a 6
A
3
0
5 10 15
–3 B
–6
Figure 4.22 Fixed airway obstruction (a, schematic; b, actual). Both

the inspiratory and expiratory portions of the loop are flattened as
a consequence of elevated resistances
4.3.4 Evaluation of Bronchodilator Therapy
Despite a lack of convincing evidence, bronchodilators are

frequently used to treat infants with bronchopulmonary dys-
plasia. This disorder affects the airways and may have an
element of bronchospasm. The F-V loop can be used to
objectively assess the efficacy of bronchodilator therapy and
determine whether the benefit outweighs the risk.
Figure 4.23 shows a baseline evaluation of resistance, with
lower than expected PIFR and PEFR, suggesting elevated
a 6
PIFR
3
0
5 10 15
PEFR
–3
–6
Figure 4.23 Increased expiratory resistance, pre-treatment (a, sche-

matic; b, actual). This baby is showing increased resistance, with
markedly diminished peak inspiratory and expiratory flow rates
(arrows) (Used with permission from Fanaroff and Martin’s
Neonatal-Perinatal Medicine, edn 10, Martin R et al., editors,
Copyright Elsevier, 2015)
resistance. Figure 4.24 is the same patient immediately after

receipt of a bronchodilator and under the same ventilatory
parameters. In this case therapy brought about a significant
improvement in resistance, with increases in both PIFR and
PEFR
a 6
PIFR
3
0
5 10 15
–3
PEFR
–6
Figure 4.24 Post-treatment (a, schematic; b, actual). There has been

a significant improvement in both the PIFR and PEFR. The loop has
“opened” and the tidal volume delivery has also improved (Used
with permission from Fanaroff and Martin’s Neonatal-Perinatal
Medicine, edn 10, Martin R et al., editors, Copyright Elsevier, 2015)
4.3.5 Excessive Dynamic Airway Collapse
Excessive dynamic airway collapse (EDAC) is a condition

that may be congenital or acquired, in which there is airway
luminal narrowing during expiration creating a severe expira-
tory flow restriction. The appearance of the F-V loop shows a
rapid decline from the PEFR after a sharp acceleration to
peak (Fig. 4.25).
a 10
5
0
20 40 60
B
–5
A
–10
Figure 4.25 Excessive dynamic airway collapse (a, schematic; b,

actual). The early phase of expiration (A) is normal, but note the
“notching” at end expiration (arrow). Airway luminal narrowing,
either congenital or acquired, may collapse as flow or pressure
declines
Suggested Reading
Bhutani VK. Clinical applications of pulmonary function and graph-
ics. Semin Neonatol. 2002;7:391–9.
Carlo W, DiFiore JM. Assessment of pulmonary function. In: Martin
RJ, Fanaroff AA, Walsh MC, editors. Fanarof and Martin’s
neonatal-perinatal medicine: diseases of the fetus and infant.
Philadelphia: Elsevier/Mosby; 2011. p. 1092–106.
Fisher JB, Mammel MC, Coleman JM, Bing D, Boros SJ. Identifying
lung overdistension during mechanical ventilation by using
volume-pressure loops. Pediatr Pulmonol. 1988;5:10–4.
Chapter 5
Trend Screens

126 Chapter 5. Trend Screens
Another benefit of the microprocessor-based technology is

the ability to store data and to present it in multiple formats.
Trend screens are now an integral component of most
present-day mechanical ventilators and enable the clinician
to follow changes over time and even to reconstruct past
clinical events.
Trend screens may present both graphic and numeric data.
Ventilatory parameters can be displayed in a graphic format
over several hours or numerically on a minute-by-minute
basis. A typical trend screen is shown in Fig. 5.1. The upper
half shows hourly graphic trends for four selected ventilator
parameters. The lower half lists selected parameters in tabu-
lar form from minute to minute. All of the parameters may be
changed, and the clinician can scroll through the screen to
find times of interest. Although this may seem obvious, trend
screens are of no value if they are not customized by the user
to display values of interest for a particular patient. Most
ventilators allow trending of far more parameters than are
used in the neonatal intensive care unit (NICU), because so
many of the current devices are “cradle-to-grave” single plat-
form machines. Indices useful for adult intensive care may be
meaningless in the NICU, and the default screen rarely is
useful.
Chapter 5. Trend Screens 127
a PRESSURE A/C TRENDS
Vte/kg (mL/kg)
15 100
13
FiO2 (%)
10 75
cmH2O 50
Ppeak 5 25
4 0
1 2 3 4 5 6
0
1 2 3 4 5 6
Cdyn (mL/cm2O)
cmH2O 15 8
Ppeak (H2O)
Pmean
10 6
40
bpm
5
4
2
Rate 0 0
1 2 3 4 5 6 1 2 3 4 5 6
3.1
mL/kg
Time
Ppeak
cmH2O
Pmeen
cmH2O
PEEP
cmH2O
Rate
bpm
Vte/kg
mL/kg
Vte/kg
mL/kg
Cdyn/kg
L/cmH2O
Leak
%
C20/C Events
Vte/kg 11:46 20 9 5 44 6.2 6.0 0.39 2 2.0

11:47 19 9 4 42 6.6 5.5 0.41 14 1.5
41%
11:48 20 9 5 40 6.2 6.3 0.41 0 1.5
FiO2 11:49 19 9 1 40 6.3 6.4 0.32 0 1.6

11:50 16 4 0 40 5.2 5.3 0.30 0 1.6
40 12 0.50 0 1.5 40
Rate Insp Press Ins Time PEEP Flow Trig FiO2
0.50 sec 1.00 sec
1:2.0
Figure 5.1 Graphic monitor trend screen (a, schematic; b, actual).

On many devices, these screens have extensive customization, allowing
the operator to select the parameters on the vertical axis, for the graphic
displays, and within the charted numerical values. There is often the abil-
ity to change the time window displayed from short, a few hours, to
prolonged, a day or more
Trend screens may be particularly useful in re-creating

prior clinical scenarios. When we round as a team in the
morning, it is uncommon that events that occurred overnight
will be reported by those who responded. It is a bit like the
party game we have all played, in which one person whispers
information to his or her neighbor, and it is passed around the
circle. What comes out the other end often bears little resem-
blance to what went in. Similarly we get the edited version of
the night’s events. Use of trending screens in many cases
allows us to see what actually happened, at least as far as the
recorded information allows. In this way a more realistic
evaluation may be made and a physiology-based solution
identified. For instance, a baby may have had a desaturation
event during the night and its etiology may be unclear. By
going back and examining the data, the clinician can assess
whether there was apnea, loss of tidal volume (Vt), broncho-
constriction, or other pathological event. An example is
shown in Fig. 5.2, with loss of Vt accompanied by tachypnea.
Figure 4.4 is an older trend screen from a baby receiving
volume-targeted ventilation. His improvement over time is
shown by the progressive decrease in inspiratory pressure. As
his compliance improved, the ventilator automatically
weaned the pressure.
a PRESSURE A/C TRENDS
20 40
22
FiO2 (%)
Vti (mL)
15 30
cmH2O 10 20
Ppeak
5 10
13.7
mL
Pmean (cmH2O) 0
20
2 4 6 8 10 12
0
80
2 4 6 8 10 12
Rate (bpm)
Vti
15 60
12.3
mL
10
5
40
20
Vte 0 0
2 4 6 8 10 12 2 4 6 8 10 12
5.6
mL/kg
Time
Vti
mL
Vte
mL
tE
Ppeak
cmH2O
PEEP
cmH2O
Pmean
cmH2O
Vdel
mL
Auto PEEP
cmH2O
FiO2
%
Events
Vti/kg 11:40 12.2 10.9 1:35 22 5 8 31.2 xxx 21

11:41 12.2 10.8 1:35 22 5 8 31.1 xxx 21
21
%
11:42 12.3 10.9 1:35 22 5 8 31.2 xxx 21
FiO2 11:43 12.3 10.9 1:35 22 5 8 31.1 xxx 21

11:54 12.3 10.9 1:35 22 5 8 31.2 xxx 21
30 17 0.40 5 0.4 21
Rate Insp Pres Insp Time PEEP Flow Trig FiO2
0.40 sec 1.60 sec
1:4.0
Figure 5.2 A trend screen (a, schematic; b, actual) displaying loss of

Vt accompanied by tachypnea
The trend screen shown in Fig. 5.3 shows the effect of sur-
factant administration, given around the 5 hour mark. Note
how compliance improves, tidal volume increases, and peak
pressure is weaned.
As medical record technology advances, it is likely that
longer periods of data retention and direct interfacing of
ventilator-derived data and the electronic medical record will
become the standard.
Figure 5.3 A trend screen showing the effects of surfactant admin-

istration around the 5 hour mark. Compliance improves, tidal vol-
ume increases, and peak pressure is decreased
Suggested Reading
Donn SM, Sinha SK. Assisted ventilation and its complications. In:
Martin RJ, Fanaroff AA, Walsh MC, editors. Fanarof and Martin’s
neonatal-perinatal medicine: diseases of the fetus and infant.
Mosby: Elsevier; 2011. p. 1116–40.
Hagus CK, Donn SM. Pulmonary graphics: basics of clinical applica-
tion. In: Donn SM, editor. Neonatal and pediatric pulmonary
graphics: principles and clinical applications. Armouk: Futura
Publishing Company; 1988. p. 81–128.
Chapter 6
Miscellaneous Conditions

134 Chapter 6 Miscellaneous Conditions
6.1 Endotracheal Tube Leaks

Because cuffed endotracheal tubes are not used in newborns,
there is always some degree of gas leak around the endotra-
cheal tube. Leaks can be detected graphically, using either
waveform or loop analysis.
Figure 6.1 is a tidal volume (Vt) waveform demonstrating
a large endotracheal tube leak. Normally, the descending por-
tion of the waveform reaches the zero baseline at end-
expiration. However, in the face of a leak, the waveform fails
to reach the baseline and may have the appearance similar to
a pressure waveform with positive end-expiratory pressure
(PEEP).
6.1 Endotracheal Tube Leaks 135
a
15
10
Vt (mL)
5
0
–5 1 2 3 4 5

The volume waveform is abnormal; it fails to reach the zero baseline
(arrows)
Leaks also affect the pressure-volume (P-V) and the

flow-volume (F-V) loops. Fig. 6.2 shows a P-V loop from
a baby with a large endotracheal tube leak. The defla-
tion limb stops before reaching the PEEP value (the
straight solid line is an artifact drawn by the monitor).
a 15
Paw (cmH2O) - Vt (mL)

10
–20 0 20 40

The P-V loop fails to return to the x-axis (0 volume). The straight
line connecting the terminus of the loop to the abscissa is an artifact
drawn by the monitor (arrow)
Fig. 6.3 is the F-V loop from the same patient. Here the
expiratory flow terminates prematurely, reaching a zero
flow state long before the origin (again, the straight solid
line is a monitor-generated artifact). Many ventilators
are able to quantify the leak by comparing the difference
between inspired and expired Vt; some will demonstrate
this.
Graphics can help in the treatment of leaks. Generally the
first approach is to change the position of the baby’s head
and neck to see if the leak is minimized. Increasing inspira-
tory flow may also help. After each adjustment, rechecking
the waveform, loops, or leak display will provide information
about the patient’s response.
a
6
3
0
5 10 15
–3
–6

The F-V loop terminates prematurely and fails to return to the ori-
gin. The straight line connecting the terminus of the loop to the
ordinate is an artifact drawn by the monitor (arrow)
6.2 Turbulence
Turbulence can occur whenever there is something that dis-
turbs laminar airway flow. Most often, this results from secre-
tions or condensation in the airway or the ventilator circuit.
Turbulence creates a “noisy” flow signal, which alters both
the flow waveform and the F-V loop.
Figure 6.4 displays a very turbulent flow waveform. In this
case, it is virtually all inspiratory flow (yellow or red). Fig. 6.5
from the same patient, demonstrates severe inspiratory tur-
bulence with some mild expiratory turbulence on the F-V
loop.
This pattern should alert the health care provider to exam-
ine the baby and to look carefully for secretions, condensa-
tion, or other obstructive matter in the airway, endotracheal
tube, sensor, or ventilator circuit. Some centers have used this
information to determine when to suction a mechanically
ventilated baby rather than performing suctioning on a rou-
tine basis.
6.2 Turbulence 141
a Flow (L/min) 6
3
0
2 4 6 8 10 12
–3
–6
Figure 6.4 Turbulence (a, schematic; b, actual). The F-V loop also
demonstrates a “noisy,” irregular signal (non-laminar flow)
a 6
3
0
5 10 15
–3
–6
Figure 6.5 Turbulence (a, schematic; b, actual). The flow waveform

demonstrates a “noisy,” irregular signal (non-laminar flow)
Suggested Reading
Jarreau P-H, Louis B, Dassieu G, Desfrere L, Blanchard PW, Moriette
G, Isabey D, Harf A. Estimation of inspiratory pressure drop in
neonatal and pediatric endotracheal tubes. J Appl Physiol.
1999;87:36–46.
Chapter 7
Clinical Cases
7.1 Case 1
A 29-week, 1,250-g male, is now 24 h old. He has received
three doses of surfactant. The current ventilator settings are
synchronized intermittent mandatory ventilation (SIMV)
with a rate of 30; peak inspiratory pressure (PIP) 26; positive
end-expiratory pressure (PEEP) 4; inspiratory time (Ti)
0.35 s; and fraction of inspired oxygen (FiO2) 0.55. The spon-
taneous respiratory rate (RR) is 75. Arterial blood gas
(ABG): pH 7.21; partial pressure of carbon dioxide (PCO2)
62; and partial pressure of oxygen (PO2) 50. The measured

144 Chapter 7. Clinical Cases
tidal volume (Vt) varies from 2 to 5 mL/kg. The graphics are

shown in Fig. 7.1 (showing the two populations of breaths
during SIMV, mechanical and spontaneous).
Which of these is the best choice under the circumstances?
(a) No changes needed, recheck ABG in 2 h
(b) Increase ventilator rate to 60, increase PEEP to 6, increase
PIP to 28
(c) Switch to assist/control ventilation (A/C) mode, rate 40,
add volume targeting with inspiratory pressure limit 30 (to
yield 4–6 mL/kg Vt), increase PEEP to 6
(d) Switch to high-frequency oscillation (HFO), rate 12 Hz, and
adjust the amplitude for adequate chest wiggle
(e) Switch to continuous positive airway pressure (CPAP) at 6
with pressure support ventilation (PSV) of 20
Answer:
(c) Switch to A/C mode, rate 40, add volume targeting with
inspiratory pressure limit 30 (to yield 4–6 mL/kg Vt),
increase PEEP to 6
This infant is showing the effects of inadequate respiratory
support. His supported breaths have adequate Vt, but his
spontaneous breaths do not and are too small, thus resulting
in tachypnea. His lung volume also is inadequately sup-
ported; the persistently high FiO2 after surfactant indicates
inadequate mean airway pressure (Paw). The A/C mode pro-
vides support for all breaths, with the rate of 40 providing
apnea protection and the pressure limit allowing the pressure
to vary based on Vt. The higher PEEP will begin the recruit-
ment process. Increasing the SIMV rate may address the
problem but still has the potential for either too much or too
little support. HFO is not needed here, and CPAP with PSV
does not protect against apnea or allow volume targeting.
7.1 Case 1 145
Figure 7.1 Case 1 (Note that this monitor draws the F-V loop
reversed and inverted compared to previous examples)
7.2 Case 2
A 700-g female is now 10 days old and is receiving A/C at a
control rate of 40 (spontaneous rate, 60); Ti 0.2 s; volume tar-
get, 4–6 mL/kg; inspiratory pressure limit set at 28; PEEP 6;
FiO2 0.35. The low-volume and high-pressure alarms are
sounding. The most recent ABG: pH 7.21; PCO2 60; PO2 55;
oxygen saturation in arterial blood (SaO2) 93 %. The current
graphic screen is shown in Fig. 7.2.
Which of these represents the best choice?
(a) Increase RR to 60
(b) Switch to HFO, 15 Hz, amplitude adjusted for wiggle
(c) Switch to high-frequency jet ventilation (HFJV), with
mean Paw of 2 cm H2O above = conventional mechanical
ventilation (CMV), PIP 28
(d) Evaluate the inspiratory gas flow waveform
(e) Increase the PIP limit to allow higher Vt
Answer:
(d) Evaluate the inspiratory gas flow waveform
The problem here is inadequate Vt delivery, evidenced by
tachypnea, low-Vt/high-pressure alarms, and respiratory aci-
dosis. The likely culprit is a Ti that is too short. In flow-cycled
A/C, Ti is a limit variable, that is, the longest allowed time.
This baby’s time constants do not allow enough gas flow in
the 0.2 s, so PIP increases in an to attempt to move gas (and,
hence, volume) faster. The flow waveform will show this and
also will show the immediate improvement with a longer Ti.
Fig. 7.3 shows the impact of this change.
7.2 Case 2 147
Figure 7.2 Case 2
Figure 7.3 Case 2

7.3 Case 3
A 6-day-old female born at 26 weeks has been relatively
stable receiving A/C with volume targeting. The nurse calls
you to the bedside because the ventilator is alarming “high
pressure.” Vt is 2.5 mL/kg even though the PIP is 30 cm H2O,
the maximum allowed. Previous pressure requirements had
been in the 20–22 cm H2O range.
Which is your best response?
(a) You obtain a chest radiograph to look for a pneumothorax
(b) You look at the Vt waveform and pressure-volume (P-V)
loop to compare inspiratory and expiratory volumes
(c) You order an extra dose of surfactant
(d) You switch to HFJV
(e) You request a more experienced respiratory therapist
Answer:
(b) You look at the Vt tracing and P-V loop to compare inspi-
ratory and expiratory volumes
The issue here is the low Vt in spite of high PIP. Either the
lung is suddenly stiffer or there is a leak preventing all of the
gas from reaching the alveoli. The graphics show higher inspira-
tory versus expiratory volumes—evidence of air leak (Fig. 7.4).
A chest radiograph may be helpful, but is not the solution;
additional surfactant will not help either. HFJV is probably not
needed. Note that, in Fig. 7.5, neither the flow-volume (F-V)
nor the pressure-volume (P-V) loop closes, which is indicative
of a leak. Try to identify the source of the leak.
7.3 Case 3 149
Figure 7.4 Case 3
Figure 7.5 Case 3

7.4 Case 4
A 27-week preterm newborn is intubated shortly after birth
and placed on mechanical ventilation. She is transferred to
the NICU and placed on mechanical ventilation using pres-
sure control in the A/C mode. The initial waveforms are
shown in Fig. 7.6. A dose of surfactant is administered, result-
ing in the changes shown in Fig. 7.7. The ABG now shows
pH 7.46; PCO2 28; and PO2 66.
Which of the following statements is NOT true?
(a) There has been a marked improvement in dynamic
compliance
(b) The Vt is too high
(c) Weaning of pressure is indicated
(d) Decrease the rate to diminish the hypocapnia
(e) A switch to volume-targeted ventilation might be beneficial
Answer:
(d) Decrease the rate to diminish the hypocapnia (False)
The respiratory alkalosis appears to be the result of exces-
sive mechanical support in the face of rapidly improving
compliance following the administration of surfactant. The
appropriate therapeutic intervention is to provide less sup-
port, and this is best done by either directly decreasing the
PIP and measuring its impact on Vt or by using a volume-
targeting system to do it for you. Volume targeting results in
decreased mortality and bronchopulmonary dysplasia.
Decreasing PIP and/or PEEP blindly may or may not work—
use the measurements and the graphic displays of lung
mechanics! Decreasing the control rate during A/C in an
infant already breathing faster than it has no effect, because
the rate is a minimum, not a fixed support level.
7.4 Case 4 151
Figure 7.6 Case 4
Figure 7.7 Case 4

7.5 Case 5
A 3-day-old 1,000 g baby receives pressure-targeted SIMV at
a rate of 60; PIP of 26; PEEP of 6; FiO2 0.6; and Ti is 0.4 s. The
arterial pH is 7.23; PCO2 57; PO2 54; and SaO2 90 %. His C20/C
is 0.75, and a P-V loop shows limited hysteresis and flattening
of the loop at the top (Fig. 7.8a).
How do you interpret the graphic display?
(a) He is still surfactant deficient and would benefit from
additional surfactant therapy
(b) His functional residual capacity (FRC) is low and he is
gas trapping
(c) He has a fixed expiratory obstruction
(d) He is overdistended from a high Vt
(e) He is overdistended from a prolonged Ti
Answer:
(d) He is ovedistended from a high Vt
Gas exchange can deteriorate if the lung is either under- or
overdistended. The C20/C ratio is a measure of lung overdis-
tension, relating the C value for the final 20 % of pressure
change to the overall C for the measured breath. A value less
than 1.0 suggests possibly significant overdistension.
Surfactant deficiency could be a component but is not the
reason for the finding; the FRC would be high with gas trap-
ping. A prolonged Ti would be unlikely to produce a low
C20/C. Figure 7.8b shows normalization of pulmonary mechan-
ics after reducing the PIP. The “beaking” is now gone.
7.5 Case 5 153
Figure 7.8 Case 5

7.6 Case 6
A 7-day-old 25-week infant is receiving A/C ventilation at a
control rate of 40 (spontaneous rate 98); PIP 23 (delivering Vt
5.0 mL/kg); PEEP 5; FiO2 0.34. The ventilator is alarming
“high rate.” The accompanying graphic is shown in Fig. 7.9.
How do you respond?
(a) Sedate the infant
(b) Order a chest radiograph
(c) Briefly place the infant on CPAP
(d) Change the ventilator tubing
(e) Order an ABG
Answer:
(c) Briefly place the infant on CPAP
In general, especially with the small preterm infant, any
RR greater than 80 warrants investigation for possible auto-
cycling. Auto-cycling is caused when the ventilator monitor-
ing system detects the flow signal crossing the zero baseline,
which the ventilator interprets as the patient trying to inspire.
This may be caused by several different conditions, including
water collecting in the dependent limb of the ventilator tub-
ing, hiccups, air leak, and others. Placing the infant briefly on
CPAP immediately enables making the diagnosis. If the RR
falls, it was auto-cycling. If not, look for other causes of agita-
tion. Sedation without investigation may be harmful. A chest
radiograph takes time and delays the diagnosis. Changing the
ventilator tubing might work by accident if excessive rainout
is the problem. An ABG may be helpful but is not necessary
to make the diagnosis. When auto-cycling is suspected, check
carefully for leaks, excessive condensation in the circuit, or
other sources of aberrant triggering. Auto-cycling from leaks
may also be stopped by raising the assist sensitivity above the
level of the leak.
7.6 Case 6 155
Figure 7.9 Case 6

7.7 Case 7
Shortly after the change in shift, you are called to the bedside
to evaluate a 1-day-old 26-week female infant with RDS, who
has received two doses of surfactant. By observing the pat-
tern on the graphic monitor shown in Fig. 7.10, the nurse is
very concerned that the baby has deteriorated.
How do you react?
(a) The baby has horrible compliance, increase the PIP
(b) The baby has horrible compliance, increase the PEEP
(c) The baby has horrible compliance, give another dose of
surfactant
(d) The baby has horrible compliance, switch to HFO
(e) The baby has reasonable compliance, do nothing
Answer:
(e) The baby has reasonable compliance, do nothing.
This is a classic case of improperly scaled axes on the
graphic monitor. Always check the axes before attempting to
interpret the findings. Graphics are indeed all about pattern
recognition, and if you saw this pattern on properly scaled
axes, you would be correct in diagnosing horrible compliance.
However, proper adjustment of the axes to contain the entire
loop and getting the abscissa and ordinate to be as close to 1:1
as possible demonstrates a compliance axis of greater than
60° and reasonable compliance (Fig. 7.11).
7.7 Case 7 157
Figure 7.10 Case 7
Figure 7.11 Case 7

7.8 Case 8
You are managing a 2-day-old, 41 week male infant with
meconium aspiration syndrome. He is receiving mechanical
ventilation with pressure control A/C at a rate of 60; PIP of
28; PEEP of 6; inspiratory time of 0.5 s; and FiO2 of 0.5. His
last ABG showed a pH of 7.29; PO2 of 88; and PCO2 of 53.
The nurse calls you to the bedside because she is concerned
about his “barrel chest” appearance. Review of the graphic
monitor reveals the pattern shown in Fig. 7.12.
Which changes might you consider?
(a) Increase the ventilator rate
(b) Switch to a volume-targeted modality
(c) Decrease the Ti
(d) Reduce the PEEP
(e) Decrease the PIP
Answer:
(b) Switch to a volume-targeted modality
The flow waveform shows that the baby is gas trapping
(See also Fig. 2.14) and is at risk for developing a pneumotho-
rax. Increasing the ventilator rate will only aggravate this
situation. Switching to a volume-targeted modality is a rea-
sonable choice. Pressure control uses variable flow gas deliv-
ery, and the rapidly accelerating inspiratory flow could be
contributing to the gas trapping. Decreasing the Ti might also
be beneficial, but one needs to be careful in pressure control
because the shorter Ti might result in even greater inspiratory
flow to meet the specified pressure conditions. Reducing
PEEP is not a good idea, because further collapse of small
airways will accentuate the ball-valve effect of meconium and
exacerbate gas trapping. The baby is oxygenating well and
has only a modest oxygen requirement, so he might tolerate
a slight decrease in PIP. Care will need to be taken to be sure
that this decrease in amplitude (PIP-PEEP) does not
adversely affect minute ventilation and CO2 removal.
7.8 Case 8 159
Figure 7.12 Case 8

7.9 Case 9
A 25 week baby is admitted to the NICU directly from the
delivery room. She has been intubated and given a dose of
surfactant. She has minimal respiratory effort and a decision
is made to mechanically ventilate her. Initial settings include
FiO2 of 0.4; rate of 40; PIP of 20; and PEEP of 4. After a few
minutes, her SaO2 is only 87 % and her P-V loop is shown in
Fig. 7.13.
What adjustments do you make?
(a) Increase the FiO2 until the saturation is higher.
(b) Increase the PEEP and perhaps the PIP
(c) Increase the rate to 50
(d) Increase the PIP to 25
(e) Give more surfactant now
Answer:
(b) Increase the PEEP and perhaps the PIP
The P-V loop demonstrates the need for a higher opening
pressure to recruit the lung. The best way to do this is to
increase the PEEP, with perhaps a concomitant increase in
the PIP. The baby is already receiving supplemental oxygen,
and increasing this might improve oxygenation but will not
improve lung mechanics. Increasing the rate will facilitate
ventilation but will have only modest effects on increasing
mean Paw. Increasing just the PIP will be less effective than
raising the PEEP. Additional surfactant should not be given
for at least 12 h after the first dose.
7.9 Case 9 161
Figure 7.13 Case 9

7.10 Case 10
A term baby develops respiratory distress and severe stridor
at 30 min of life. The chest radiograph shows clear lung fields.
An ABG reveals severe hypercapnia; pH is 7.07; PCO2 is 112;
and PO2 is 55. A chest radiograph is clear. The baby is
intubated and the graphics are shown in Figs. 7.14 (wave-
forms) and 7.15 (loops).
What phenomenon is present?
(a) Gas trapping
(b) Hyperinflation
(c) Increased inspiratory resistance
(d) Increased expiratory resistance
(e) Turbulence
Answer:
(d) Increased expiratory resistance
7.10 Case 10 163
Figure 7.14 Case 10
Figure 7.15 Case 10

Markedly increased expiratory resistance is shown in both

the flow waveform and the F-V loop. There is severely
reduced expiratory flow. There is a virtual absence of the
accelerating portion of the expiratory flow waveform and an
extraordinarily slow return to baseline during the decelerat-
ing expiratory flow phase. The loops show two abnormalities.
The P-V loop shows a high opening pressure (requiring a
higher level of PEEP) and the F-V loop demonstrates a sig-
nificant reduction in the peak expiratory flow rate (PEFR),
which is barely half of the peak inspiratory flow rate (PIFR).
Using graphics, the PEEP was sequentially increased until
the lung mechanics normalized and the flow waveform
appeared appropriate (Fig. 7.16). Note that nearly 15 cm
H2O of PEEP was required. The baby was found to have a
vascular ring.
7.10 Case 10 165
Figure 7.16 Case 10

7.11 Case 11
A small preterm infant is receiving mechanical ventilation for
RDS and has been weaning steadily. There is a sudden venti-
lator alarm and the nurse summons you to the bedside. The
baby and ventilator appear to be asynchronous and the ven-
tilator is cycling at 120 breaths/min. The waveforms are
shown in Fig. 7.17 and the F-V is shown in Fig. 7.18.
What is the best explanation for the sudden change?
(a) Pneumothorax
(b) Circuit disconnection
(c) Extubation
(d) Auto-cycling
(e) Gas trapping
Answer:
(b), (c), and (d) are all correct
The most likely scenarios are either circuit disconnection
or extubation, leading to auto-cycling. Neither pneumothorax
nor gas trapping would be expected to produce these find-
ings. The clue that this is more than just a simple gas leak can
be seen in the F-V loop. The fainter complete loop is a refer-
ence loop, and the loop that is shown after the disconnection
or extubation demonstrates only inspiratory flow. No expira-
tory flow at all is detected by the transducer.
7.11 Case 11 167
Figure 7.17 Case 11
Figure 7.18 Case 11

Suggested Reading
Donn SM, Becker MA, Nicks JJ. Special ventilation techniques 1:
patient-triggered ventilation. In: Goldsmith J, Karotkin E, editors.
Assisted ventilation of the newborn. 5th ed. Philadelphia:
Saunders; 2011. p. 220–35.
Klingenberg C, Wheeler KI, Davis PG, Morley CJ. A practical guide to
neonatal volume guarantee ventilation. J Perinatol. 2011;31:575–85.
Sinha S, Donn SM. Volume-targeted ventilation. In: Goldsmith J,
Karotkin E, editors. Assisted ventilation of the newborn. 5th ed.
Philadelphia: Saunders; 2011. p. 186–200.
Spitzer AR, Clark RH. Positive-pressure ventilation in treatment of
neonatal lung disease. In: Goldsmith J, Karotkin E, editors.
Assisted ventilation of the newborn. 5th ed. Philadelphia:
Saunders; 2011a. p. 163–85.
Spitzer AR, Clark RH. Special ventilation techniques 2: lung protec-
tive strategies. In: Goldsmith J, Karotkin E, editors. Assisted ven-
tilation of the newborn. 5th ed. Philadelphia: Saunders; 2011b.
p. 235–49.
Wheeler K, Klingenberg C, McCallion N, Morley CJ, Davis
PG. Volume targeted vs. pressure limited ventilation in the neo-
nate. Cochrane Database Syst Rev. 2010;(11):CD003666.
Wheeler KI, Klingenberg C, Morley CJ, Davis PG. Volume-targeted
versus pressure-limited ventilation for preterm infants: a system-
atic review and meta-analysis. Neonatology. 2011;100:219–27.
Chapter 8
Further Reading
Abbasi S, Sivieri E, Roberts R, Kirpalani H. Accuracy of tidal

volume, compliance, and resistance measurements on neo-
natal ventilator displays: an in vitro assessment. Pediatr
Crit Care Med. 2012;13:e262–8.
Abubakar KM, Meszler M. Patient-ventilator interactions in
new modes of patient-triggered ventilation. Pediatr
Pulmonol. 2001;32:71–5.
Becker MA, Donn SM. Real-time pulmonary graphic moni-
toring. Clin Perinatol. 2007;34:1–17.
Bhutani VK. Clinical applications of pulmonary function and
graphics. Semin Neonatol. 2002;7:391–9.
Bhutani VK, Sivieri EM. Clinical use of pulmonary mechan-
ics and waveform graphics. Clin Perinatol. 2001;28:
487–503.
Cunningham MD. Intensive care monitoring of pulmonary
mechanics for preterm infants undergoing mechanical
ventilation. J Perinatol. 1989;9:56–9.
Devlieger H, Bayet T, Lombet J, Naudé S, Eugène C. The
flow-pressure plot: a new look on the patient-ventilator
interaction in neonatal care. Semin Perinatol. 2002;26:
425–31.
Donn SM, editor. Neonatal and pediatric pulmonary
graphics: principles and clinical applications. Armonk:
Futura; 1998.

170 Chapter 8 Further Reading
Fisher JB, Mammel MC, Coleman JM, Bing DR, Boros

SJ. Identifying lung overdistension during mechanical ven-
tilation using volume-pressure loops. Pediatr Pulmonol.
1988;5:10–4.
Huelitt MJ, Donn SM. Monitoring interactions between
spontaneous respiration and mechanical inflations. In:
Rimensberger PC, editor. Pediatric and neonatal mechani-
cal ventilation: from basics to clinical practice. Heidelberg:
Springer; in press.
Huelitt MJ, Ouellete P, Donn SM. Waveform analysis. In:
Rimensberger PC, editor. Pediatric and neonatal mechani-
cal ventilation: from basics to clinical practice. Heidelberg:
Springer; in press.
MacDonald KD, Wirtschafter DD. Continuous neonatal pul-
monary mechanics with the BICORE CP-100 monitor.
Neonatal Intensive Care. 1992;5:55–61.
Mammel MC. Bedside tidal volume measurements: GIGO?
Crit Care Med. 2002;30:2606.
Mammel MC, Fisher JB, Bing DR, Gatto CW, Boros SJ. Effect
of spontaneous and mechanical breathing on dynamic lung
mechanics in hyaline membrane disease. Pediatr Pulmonol.
1990;8:222–5.
Migliori C, Gallina MR, Bona G. Practical applications of
monitoring respiratory mechanics in newborn. Minerva
Pediatr. 1999;51:57–64.
Nicks JJ. Neonatal pulmonary graphics. In: Donn SM, Sinha
SK, editors. Manual of neonatal respiratory care. 3rd ed.
New York: Springer Science; 2012. p. 167–80.
Rigo V, Graas E, Rigo J. Precision of continuous neonatal
ventilator respiratory mechanics is improved with selected
optimal respiratory cycles. Eur J Pediatr. 2012;171:689–96.
Rosen WC, Mammel MC, Fisher JB, Coleman JM, Bing DR,
Holloman KK, et al. The effects of bedside pulmonary
mechanics testing during infant mechanical ventilation: a
retrospective analysis. Pediatr Pulmonol. 1993;16:147–52.
Sinha SK, Nicks JJ, Donn SM. Graphic analysis of pulmonary
mechanics in neonates receiving assisted ventilation. Arch
Dis Child Fetal Neonatal Ed. 1996;75:F213–8.
Erratum
Pulmonary Mechanics and Loops
S.M. Donn, M.C. Mammel, Neonatal Pulmonary Graphics:

A Clinical Pocket Atlas, DOI 10.1007/978-1-4939-2017-4,
DOI 10.1007/978-1-4939-2017-4_9
The publisher regrets the incorrect numbers published on

page 79 of the print and online versions of this book. The
corrections are given below.
Chapter 4, page 79
Figure 4.2a
The numbers “458” and “308” at the right hand margin
should read “45°” and “30°” (degrees) respectively.
The online version of the original chapter can be found at

http://dx.doi.org/10.1007/978-1-4939-2017-4_4
S.M. Donn, M.C. Mammel, Neonatal Pulmonary Graphics: E1

Index
A P-V loop, 136–137

Air hunger, 96–97 volume waveform, 134–135
Air leak, 148–149 Excessive dynamic airway
Assist/control (A/C) ventilation collapse (EDAC),
clinical case, 146–147 122–123
pressure-targeted, 52–53
volume-targeted, 54–55
Auto-cycling, 36–37 F
Auto-triggering, 36–37 Fixed airway obstruction, 116–117
Auto-weaning, 80 Flow-cycling, 32–33
Flow-volume (F-V) loop
anatomy, 110–111
B bronchodilator therapy,
Bronchodilator therapy 118–121
post-treatment, 120–121 elevated expiratory
pre-treatment, 118–119 resistance, 114–115
Bronchopulmonary dysplasia, 150 elevated inspiratory
resistance, 112–113
endotracheal tube leaks,
C 138–139
Compliance, 76, 156–157 excessive dynamic airway
Continuous positive airway collapse, 122–123
pressure (CPAP), fixed airway obstruction,
154–155 116–117
turbulence, 140–141
Flow waveforms
E anatomy, 24–25
EDAC. See Excessive dynamic auto-cycling, 36–37
airway collapse (EDAC) continuous, 24
Endotracheal tube leaks cycling mechanisms, 30–31
flow waveform, 34–35 endotracheal tube leaks,
F-V loop, 138–139 34–35

A Clinical Pocket Atlas, DOI 10.1007/978-1-4939-2017-4,
172 Index
Flow waveforms (cont.) M

expiratory phase, 26 Mean airway pressure, 14–15
flow-cycling, 32–33 baseline waveforms, 62–63
flow rate and shape, 36–37 determinants, 60
gas trapping, 28–29 ways to increase, 60–61
increased expiratory inspiratory time effect, 70–71
resistance, 28, 29 oxygenation, 60
peak inspiratory, 24 PEEP effect, 66–69
pressure control ventilation, PIP effect, 64–65
40, 41 ventilator rate, 72–73
pressure-limited ventilation, 39 Mechanical ventilation
rise time adjustment, 40–41 mean airway pressure
spontaneous breath, 42–43 baseline waveforms, 62–63
volume control ventilation, determinants, 60
26–27, 39 ways to increase, 60–61
F-V loop. See Flow-volume inspiratory time effect,
(F-V) loop 70–71
oxygenation, 60
PEEP effect, 66–69
G PIP effect, 64–65
Gas trapping, 28–29 ventilator rate, 72–73
Graphic screen, 4–6 vs. pulmonary mechanics, 45
ventilator mode
assist/control (see Assist/
H Control (A/C))
Heated wire anemometer, 2 definition, 45
Hyperinflation IMV (see Intermittent
C20/C ratio, 82–83 mandatory ventilation
P-V relationship, 82–83 [IMV])
Hysteresis, 76, 152–153 PSV, 56–59
SIMV, 50–51
Meconium aspiration syndrome,
I 158–159
Inflection points, 76 Microprocessor-controlled
Intermittent mandatory ventilation, 30
ventilation (IMV)
dyssynchronous breathing,
48–49 N
flow and pressure waveforms, Neonatal intensive care unit
46–47 (NICU)
mechanical breaths, 46 real-time pulmonary graphics, 1
patient-triggered ventilation, 50 trend screens, 126
L O
Lung inflation, 82 Overdistension, 102
Index 173
P hysteresis, 76
Patient-triggered ventilation increased expiratory
(PTV), 50 resistance, 100–101
Peak inspiratory pressure (PIP), increased inspiratory
18–19, 64–65 resistance, 98–99
Plateau pressure, 16–17 inflection points, 76
Positive end-expiratory lung inflation, 82
pressure (PEEP), pressure overshoot
18–19 decreasing the rise time,
clinical case, 160–161 90, 94–95
mean airway pressure double peak, 90, 92
decreasing effect, 68–69 P-V curve, 90, 91
raising effect, 66–67 rise time effect, 90, 93
Pressure control ventilation surfactant administration
Pressure support ventilation compliance, 104–105
Pressure overshoot loop, 102–103
P-V loop underinflation
decreasing the rise time, normal inflation,
90, 94–95 88–89
double peak, 90, 92 PEEP and PIP
P-V curve, 90, 91 adjustments,
rise time effect, 90, 93 86–87
waveform, 22–23 work of breathing, 76
Pressure support ventilation Pressure waveforms
(PSV) anatomy, 14–15
flow volume, 40–41 inspiratory time, 20–21
partially supported breathing, overshoot, 22–23
58–59 PIP and PEEP changes,
spontaneous breathing, 18–19
56–57 plateau, 16–17
Pressure-volume (P-V) loop Proximal airway sensor, 2–3
air hunger, 96–97 PTV. See Patient-triggered
anatomy, 76–77 ventilation (PTV)
compliance axis, 76 Pulmonary loops
decreased compliance F-V loop
pressure-targeted anatomy, 110–111
ventilation, 78–79 bronchodilator therapy,
volume targeted 118–121
ventilation, 79–80 elevated expiratory
endotracheal tube leaks, resistance, 114–115
136–137 elevated inspiratory
excessive inspiratory hold, resistance, 112–113
106–109 excessive dynamic airway
hyperinflation collapse, 122–123
C20/C ratio, 82–83 fixed airway obstruction,
P-V relationship, 82–83 116–117
174 Index
Pulmonary loops (cont.) Respiratory alkalosis, 150–151

interpretation, 75 Respiratory distress syndrome
P-V loop auto-cycling, 166–167
air hunger, 96–97 increased expiratory
anatomy, 76–77 resistance, 162–163
compliance axis, 76 PEEP, 164–165
decreased compliance, Ringing. See Pressure overshoot
78–81
excessive inspiratory hold,
106–109 S
hyperinflation, 82–85 SIMV. See Synchronized
hysteresis, 76 intermittent
increased expiratory mandatory
resistance, 100–101 ventilation (SIMV)
increased inspiratory Spontaneous breathing,
resistance, 98–99 42–43
inflection points, 76 Surfactant administration
lung inflation, 82 pressure-volume (P-V) loop
pressure overshoot, 90–95 compliance, 104–105
surfactant administration, loop, 102–103
102–105 trend screens, 130–131
underinflation, 86–89 Synchronized intermittent
work of breathing, 76 mandatory ventilation
Pulmonary mechanics, 1–2 (SIMV)
Pulmonary waveforms, 8–9 clinical cases, 143–145
P-V loop. See Pressure-volume ventilator mode, 50–51
(P-V) loop volume waveform, 12–13
R T
Real-time pulmonary graphics Tachypnea, trend screen,
advantages, 1 128–129
flow diagram, 2, 3 Transducer, 2–3
graphic screen, 4–6 Trend screens
limitations, 6 graphic monitor, 126–127
proximal airway sensor, 2–3 surfactant administration
Resistance effects, 130–131
F-V loop tachypnea, 128–129
elevated expiratory, 114–115 Turbulence, 140–141
elevated inspiratory,
112–113
P-V loop U
increased expiratory, Underinflation
100–101 normal inflation, 88–89
increased inspiratory, PEEP and PIP adjustments,
98–99 86–87
Index 175
V cycling mechanisms, 30–31

Ventilator mode endotracheal tube leaks,
assist/control 34–35
pressure-targeted, 52–53 expiratory phase, 26
volume-targeted, 54–55 flow-cycling, 32–33
definition, 45 flow rate and the shape,
IMV 36–37
dyssynchronous breathing, gas trapping, 28–29
48–49 increased expiratory
flow and pressure resistance, 28, 29
waveforms, 46–47 peak inspiratory, 24
mechanical breaths, 46 pressure control
PSV ventilation, 40, 41
partially supported pressure-limited
breathing, 58–59 ventilation, 39
spontaneous breathing, rise time adjustment,
56–57 40–41
SIMV, 50–51 spontaneous breath,
Volume control ventilation 42–43
continuous flow, 38–39 volume control
flow waveform, 26–27 ventilation, 26–27, 39
Volume waveforms pressure
endotracheal tube leaks, anatomy, 14–15
134–135 inspiratory time, 20–21
SIMV, 12–13 overshoot, 22–23
typical, 10–11 PIP and PEEP changes,
18–19
plateau, 16–17
W pulmonary, 8–9
Waveforms respiratory parameters vs.
flow time, 8
anatomy, 24–25 volume
auto-cycling, 36–37 SIMV, 12–13
continuous, 24 typical, 10–11

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Steven M.

A Clinical Pocket Atlas

ISBN 978-1-4939-2016-7 ISBN 978-1-4939-2017-4 (eBook)

Springer New York Heidelberg Dordrecht London

Library of Congress Control Number: 2014957872

© Springer Science+Business Media New York 2015

Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com)

To my late parents, Betty and Rusty, who always

Clinicians have long struggled to make objective and

Interpretations Blood gas

Figure 1 Clinical decision algorithm

laboratory information, pulmonary graphics can greatly

Stanford, CA, USA Vinod K. Bhutani

We have witnessed tremendous technological advances since

devices with a display screen and portable computer that was

experiences with pulmonary graphics as we spent many excit-

Ann Arbor, MI, USA Steven M. Donn, MD

1 Principles of Real-Time Pulmonary Graphics . . . . . . 1

3 Impact of Mechanical Ventilation on Waveforms . . . 45

4 Pulmonary Mechanics and Loops . . . . . . . . . . . . . . . . 75

5 Trend Screens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125

6 Miscellaneous Conditions . . . . . . . . . . . . . . . . . . . . . . . 133

7 Clinical Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143

8 Further Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

S.M. Donn, M.C. Mammel, Neonatal Pulmonary Graphics: 1

and tracking of both pulmonary mechanics and trends pos-

1.2 Principles of Pulmonary Graphics

Figure 1.1 Schematic flow diagram demonstrating signal process-

Figure 1.2 Proximal airway sensor (transducer)

1.3 The Graphic Screen

a PRESSURE A/C MAIN

Figure 1.3 Typical graphic monitor screen (a, schematic; b, actual). In

Not all devices contain an auto-scale function. When pres-

S.M. Donn, M.C. Mammel, Neonatal Pulmonary Graphics: 7

Figure 2.1 Pulmonary waveforms (a, schematic; b, actual). Pressure

2.2 Volume Waveform

Figure 2.2 Volume waveform (a, schematic; b, actual). Point A is the

Evaluation of the tidal volume (Vt) waveform may be use-

Figure 2.3 Waveforms obtained during SIMV/pressure support ven-

2.3 Pressure Waveform

Figure 2.4 Schematic representation of the anatomy of a pressure

2.3.1 Plateau Pressure

If an inspiratory hold is used to prolong the inspiratory time

Figure 2.5 Plateau pressure. Prolonging inspiratory time by use of

2.3.2 Changes in PIP and PEEP

Changes in either PIP or PEEP will change the shape of the

Figure 2.6 Index pressure waveform (a, schematic; b, actual). PIP is

Figure 2.7 In this pressure waveform (a, schematic; b, actual), the

2.3.3 Change in Inspiratory Time

Increasing the inspiratory time will increase the duration of

2.3.4 Pressure Overshoot

Pressure control and pressure support ventilation utilize an

2.4 Flow Waveform

Figure 2.11 Anatomy of a flow waveform (a, schematic; b, actual).

Figure 2.12 Flow wave form during volume control ventilation

2.4.1 Increased Expiratory Resistance

Increased expiratory resistance will decrease expiratory gas

2.4.2 Gas Trapping

Figure 2.13 Flow waveform depicting increased expiratory resis-

2.4.3 Cycling Mechanisms

Cycling refers to the mechanism that transitions inspiration to

Flow-cycling takes advantage of the natural pattern of

Figure 2.16 Flow cycling (a, schematic; b, actual). During flow