CLINICAL USE OF INSPIRATORY

AND EXPIRATORY WAVEFORMS

Prepared by:
Christine T. Ilagan

VENTILATOR MODE WAVEFORM

ANALYSIS
MODE

TRIGGER

LIMIT

CYCLE

BASELINE

Volume Control

Time/px

Flow

Volume

PEEP

Pressure Control

Time/px

Pressure

Time

PEEP

Spontaneous/
Pressure Support

Px

Pressure

Flow
(exhales)

PEEP

Auto-PEEP
Incomplete emptying of alveolar gas at the end of exhalation
elevates alveolar pressure relative to airway opening (mouth)
pressure, a state referred to as auto-positive end-expiratory
pressure or auto-PEEP. This occurs when patient expiratory times
are longer than the allotted expiratory time (as occurs in
obstructive lung disease) and is signaled by persistent expiratory
flow at the time the next breath is delivered

When the problem of autoPEEP is seen on the ventilators

waveforms, the RT needs to consider several possible causes
and remedies.
The patient may need suction in order to clear obstructing

secretions out of the airways

May be time for a bronchodilator treatment which can
increase airway diameter
Increasing the flow rate, decreasing the inspiratory time or
decreasing the tidal volume can prolong expiratory time and
allow for more exhalation
Decreasing the breath rate while increasing the tidal
volume, moving to a larger endotracheal tube, or changing to
a different mode of ventilation.

Using Loops
Loops allow the practitioner to analyze the inspiratory
and expiratory phases of each breath using either flowvolume or pressure-volume tracings.
On the flow-volume loop, volume is plotted on the x
axis and flow on the y axis. Positive flow from a positivepressure breath often appears above the horizontal axis,
with expiratory flow below the axis, but this pattern may
be reversed, depending on the ventilator being used.
On most pressure-volume loops, the pressure is
plotted on the x axis; volume, on the y axis. Patienttriggered breaths will look different from time-triggered
or machine-triggered breaths on the pressure-volume
loops as the patient generates a negative pressure at the
beginning of inspiration.

Figure 5 shows a patient-triggered

breath and the resulting pressurevolume loop that traces the
inspiration and exhalation.
Figure
Figure 5.
5. Patient-triggered
Patient-triggered breath.
breath.

Figure
Figure 6.
6. Decelerating-ramp
Decelerating-ramp flow
flow
pattern
pattern on
on a
a flow-volume
flow-volume loop.
loop.

Figure 6 shows a deceleratingramp flow pattern on a flowvolume loop. It shows the rapid
increase in flow of early
inspiration reaching peak flow,
then decreasing to the end of
inspiration and reaching zero flow.

Figure
Figure 7.
7. Lower
Lower and
and upper
upper
inflection
inflection points
points for
for a
a
delivered
delivered volume.
volume.

Figure 7 shows the lower inflection point

(with tracings showing how this changes
with increasing flow) and the upper
inflection point for a delivered volume that
is at the maximum setting (overdistension
would begin to show up if delivered volume
were increased).

Figure 8 shows the beak representing

overdistension as too much volume is
delivered. In this situation, the volume
needs to be reduced to avoid the
problems related to overdistension
(barotrauma,
volutrauma,
decreased
venous return, and decreased cardiac
output).
Figure
Figure 8.
8. The
The beak
beak represents
represents
overdistension
overdistension as
as too
too much
much volume
volume
is delivered.

Comparisons of flow-volume loops can help assess the effectiveness

of a bronchodilator. In patients with obstructive disease, the
prebronchodilator

line

shows

scooped-out

pattern

on

the

expiratory side representing decreased expiratory flows and airway

obstruction.

Following

the

bronchodilator,

the

scooped-out

appearance will often change to a more linear shape from peak

expiratory flows down to the end of exhalation, which reflects the
positive effect of the bronchodilator in relieving the obstruction.
If the ventilator is delivering a decelerating flow, but the flow-volume
loop shows a flattened inspiratory flow (similar to that of a flowlimited breath), there may be something that is artificially limiting
flow. In this situation, the RCP should check for a bent or kinked
endotracheal tube, tube occlusion (possibly because the patient is
biting the tube), a saturated heat-moisture exchanger, or an
occluded expiratory filter.

SOURCES:
www.medscape.com
South Med J 2009 Lippincott Williams & Wilkins
www.derangedphysiology.com
www.slideshare.net
http://www.rtmagazine.com

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FOR
LISTENING!

MODES OF VENTILATION
Modes of ventilation are generally volume control or
pressure control, and either of these modes will give
clinicians the option of augmenting a spontaneous breath
between the mandatory breaths by using pressure support.
Mandatory breaths occur when either the patient or the
machine triggers the breath to start and the breath itself is
cycled into expiration by the machine. Spontaneous
breaths occur when the patient initiates the breath and
cycles the breath into expiration.
Pressure-support ventilation augments the spontaneous
breaths by adding flow (in a decelerating pattern) to reach a
preset inspiratory pressure; this results in an increased tidal
volume. Pressure support is available only in those modes
that allow for spontaneous breaths.
Positive end-expiratory pressure (PEEP) is one other
common addition to volume-control and pressure-control

A point can sometimes be determined, early in the inspiratory

phase, at which there is a change in the slope of the line that
shows a more rapid increase in volume per unit of pressure. This
is the lower inflection point. In the pattern of a typical
pressure-volume loop on inspiration (with no PEEP added), the
lower inflection point is thought to show the point at which alveoli
begin to fill rapidly and alveolar recruitment begins. Some have
recommended setting the PEEP level just above the lower
inflection point, but this point can change (depending on
inspiratory flow, with higher flows being related to a lower
inflection point that is also higher). At the other end of the
inspiratory tracing on the pressure-volume loop, overdistension
from too great an inspiratory volume will show up as a bird-like
beak as the lungs maximum volume is reached in the face of
continued inspiratory flow. The point at which this line begins to

MODE/WAVEFORM

DESCRIPTION

Assist-control (AC) mode

Assist-control (AC) mode. Flow, pressure, and

volume tracings of three separate breaths are
presented. The first two breaths are initiated by
the patient (patient-triggered) via a drop in airway
pressure (circled). The breath is delivered by
constant flow (flow-limited), shown as a rapid
increase in flow to a preset level. Flow lasts until a
preset tidal volume (VT) is reached (volumecycled). The exhalation port of the ventilator then
opens and the patient passively or actively
exhales. In the third breath, the preset backup
time limit is met (the patient did not initiate a
breath) and the ventilator delivers the breath
(time-triggered).

Pressure Support

Synchronized intermittent mandatory

ventilation plus pressure support ventilation
(SIMV + PSV) mode. The first and last breath
tracings are identical to those seen in SIMV.
However, during pressure-supported breaths
(bracketed), the ventilator delivers a set
inspiratory pressure which is terminated
when the flow drops below a set threshold.
Spontaneous breaths are patient-triggered,
pressure-limited, and flow-cycled.

Flow-Pressure

Flow-pressure waveforms. The left tracing

represents a constant or square waveform.
When flow is delivered at a constant rate,
resistive pressure remains fairly constant
(reflecting constant flow) while distending
pressure increases with delivery of the tidal
breath. In the tracing on the right, a
decelerating or ramp waveform is shown.
Since flow is decreasing, resistive pressure
decreases as distending pressure increases.
The net effect is an essentially constant
pressure during the tidal breath.

Synchronized intermittent Synchronized intermittent mandatory

mandatory ventilation
ventilation (SIMV) mode. As in assist-control
(SIMV)
mode, mandatory breaths are patienttriggered, flow-limited, and volume-cycled.
However, breaths taken between mandatory
breaths (bracketed) are not supported. Rate,
flow, and volume are determined by the
patients strength, effort, and lung
mechanics.

Persistence of end-expiratory flow in the setting of auto-positive

end-expiratory pressure (auto-PEEP). Auto-PEEP is end-expiratory
pressure above that generated by the ventilator. It is due to
inadequate expiratory time before the next breath is delivered. Note
that auto-PEEP generates persistent flow at the end of exhalation
compared to the desired scenario in which flow returns to zero
before the next breath is initiated. B. The expiratory hold maneuver.
At the end of exhalation, the expiratory port is occluded allowing for
equilibration of alveolar and airway opening pressures. The pressure
measured at the airway opening minus set PEEP is auto-PEEP.

The inspiratory hold maneuver. Under conditions of

constant flow (commonly 60 liters per minute) airway
opening pressure increases from PEEP to peak inspiratory
pressure (PIP). Flow is then stopped temporarily (without
allowing the patient to exhale) thus eliminating airway
resistive pressure. Airway opening pressure drops from
PIP to plateau pressure (Pplat). Then the patient is allowed
to exhale to set PEEP. The gradient between PIP and Pplat
allows for calculation of airway resistance; Pplat helps
gauge the degree of lung inflation and allows for
calculation of the static compliance of the respiratory

INTRODUCTI
ON

Most ventilators manufactured today have screens that allow

clinicians to review large amounts of patient ventilation data.
Three of the most important parameters are the pressure, flow,
and volume tracings that is plotted against time.
Time is plotted on the horizontal (x) axis and the other
parameter is plotted on the vertical (y) axis.
Data can be displayed as a single parameter in a continuous
tracing over time, called a scalar, or in combination with other
parameters, called a loop. The individual parameters may be
indexed to each other in a pressure-volume loop.

Auto-PEEP is measured by performing an expiratory hold maneuver.

Consequences of auto-PEEP include decreased cardiac preload and
increased work of breathing since auto-PEEP must be overcome by
the patient to trigger a breath. A common strategy to decrease autoPEEP is to prolong expiratory time. This may be accomplished by
decreasing RR, which runs the risk of increasing PaCO2. Hypercapnia
may be tolerated in a strategy of permissive hypercapnia provided
sudden and severe changes in pH and PaCO2 are avoided. Increasing
the inspiratory flow rate may further prolong expiratory time,
although at the cost of higher peak inspiratory pressure (PIP). In
severe cases of auto-PEEP signaled by hypotension, tachycardia, and
high airway pressures, disconnecting the patient from the ventilator
and manually decompressing the thorax may be necessary to
restore hemodynamic stability.