Ventilator waveform monitor and trouble shooting

1

Ventilator waveform monitor and trouble shooting

壢新醫院吳清平

2

Compliance

Resistance: Bronchial Tree

3

Current numerical and waveform displays do not

support anaesthesiologists optimally

Drews et.al. The right picture is worth a thousand numbers: data display in anesthesia. HUMAN

FACTORS 2006, Vol 48

Mechanical Ventilation

GraphicsGraphicsSCALARS LOOPS

Essentials of Ventilator Graphics ©2000 RespiMedu

4

SCALARS

Flow/Time

Pressure/Time

Volume/Time

Pressure-Volume Flow-Volume

LOOPS

5

Flow PatternsFlow Patterns

ACCELERATINGACCELERATING

DECELERATINGDECELERATING

SINESINE

SQUARESQUARE


Expiratory Flow PatternExpiratory Flow Pattern

Inspiration

Expiration

Time (sec)

Flo

w (

L/m

in)

Beginning of expirationexhalation valve opens

Peak Expiratory Flow RatePEFR

Duration of expiratory flow

Expiratory timeTE

6

Air Leak (Flow Trigger)Air Leak (Flow Trigger)

InspirationInspiration

ExpirationExpiration

Time (sec)Time (sec)

Flo

w (

L/m

in)

Flo

w (

L/m

in)

Leak in LPMLeak in LPM

Air TrappingAir Trapping

Inspiration

Expiration

NormalNormal

PatientPatient

Time (sec)

Flo

w (

L/m

in)

Air TrappingAuto-PEEP

}

7

Inadequate Inspiratory FlowInadequate Inspiratory Flow

Flow Flow

(L/min)(L/min)


NormalNormal

AbnormalAbnormal

Active Inspiration or AsynchronyActive Inspiration or Asynchrony

Patient’s effort

Obstruction vs Active ExpirationObstruction vs Active Expiration

Obstruction Active Expiration

Time

(sec)

NormalAbnormal

Flow

(L/min)

8

Response to BronchodilatorResponse to Bronchodilator

Before

Time (sec)

Flo

w (

L/m

in)

PEFR

After

Long TE

Higher PEFR

Shorter TE

Spontaneous BreathSpontaneous Breath

PPaw

aw

(cm

H(c

m H

220

)0

)




9

Mechanical BreathMechanical Breath

InspirationExpiration

Paw

(cm

H2O

)

Time (sec)

}}TI

Peak Inspiratory PressurePIP

PEEPPEEP

TE

Spontaneous vs. Mechanical

MechanicalMechanical

Time (sec)

SpontaneousSpontaneousPaw

(cm H2O)

Inspiration


Inspiration

10

Assisted vs ControlledAssisted vs Controlled

Time (sec)

Assisted ControlledPressure

(cmH20)

11

Components of Inflation Pressure

Components of Inflation Pressure

Begin Expiration

Paw

(cm

H2O

)

Time (sec)

Begin Inspiration

PIPPIP

Pplateau(Palveolar)

Transairway Pressure (PTA)}}Exhalation Valve Opens


Inspiratory Pause

12

Begin InspirationBegin Expiration

Pa

w(c

m H

2O

)

Time (sec)

Airway Resistance

Distending (Alveolar) Pressure Expiration

Inflation Hold(seconds)

Begin Expiration

Pa

w(c

m H

2O

))

Time (sec)Begin Inspiration

PIPPIP

Pplateau(Palveolar

TransairwayTransairway Pressure (PPressure (PTATA))}}Exhalation Valve Opens

Expiration

PIP

13

DECREASED COMPLIANCEDECREASED COMPLIANCE

Time (sec)

Paw

(c

m H

2O

)

Low CompliancePIP

PPlat

NormalNormal

PIP

PPlat

Normal PPlat(Normal Compliance)

Increased PPlat(Decreased Compliance))

Normal

PIP

Paw

(c

m H

Paw

(c

m H

22O

)O

)

Normal

Normal PPlat(Normal Compliance)

Increased PIP

} Increased PTA(increased Airway Resistance))

NormalNormalPIPPIP

PPPlatPlat

High RHigh RawawPIPPIP

PPPlatPlat

Increased Airway Resistance

14

Effect of increased FlowEffect of increased Flow

Time (sec)

Paw

(c

m H

2O

)

NormalNormalPIPPIP

High FlowHigh Flow

PPlat

PIPPIP

Dynamic Inspiratory TimeDecreased Inspiratory TimeInspiratory Time(Due to High Inspiratory Flow)

Normal

PPlat

PIP vs PplatPIP vs Pplat

Normal High Raw

High Flow Low Compliance

Time (sec)

Paw

(c

m H

2O

)

PIPPIP

PPPlatPlat

PIPPIP

PIPPIP PIPPIP

PPPlatPlatPPPlatPlat

PPlat

15

Volume vs. TimeVolume vs. Time


Expiration


Vo

lum

e (

ml)

Vo

lum

e (

ml)

Inspiratory Tidal VolumeInspiratory Tidal Volume

TTII


Air LeakAir Leak

Vo

lum

e (

ml)

Vo

lum

e (

ml)


Air LeakAir Leak


16

Active ExhalationActive Exhalation

Volume (ml)Volume (ml)


COMBINED CURVE

17

Modes of Ventilation on Scalar Graphics

Modes of Ventilation on Scalar Graphics

FLOW

PRESSURE

VOLUME

Volume VentilationVolume Ventilation

PressurePressure

Volume Volume Volume

FlowFlowPreset Peak FlowPreset Peak Flow

Preset Preset VVtt

Dependent onDependent on

CCll & R& Rawaw


(L/min)(L/min)

(cm H(cm H22O)O)

(ml)(ml)

18

Pressure Control Ventilation

Pressure Control Ventilation

FlowFlow

PressurePressure

VolumeVolumeCCll

CCll

Set PC levelSet PC level


(L/min)(L/min)

(cm H(cm H22O)O)

(ml)(ml)

Controlled Mode (Volume-Targeted Ventilation)

Controlled Mode (Volume-Targeted Ventilation)

Preset VT

Volume Cycling

Dependent on

CL & Raw


Flow

(L/m)

Pressure

(cm H2O)

Volume

(mL)

Preset Peak Flow

Time triggered, Flow limited, Volume cycled Ventilation

19

Controlled Mode (Pressure-

Targeted Ventilation)

Controlled Mode (Pressure-

Targeted Ventilation)

Pressure

Flow

Volume

(L/min)

(cm H2O)

(ml)


TimeTime--Cycled

Set PC level

Time Triggered, Pressure Limited, Time Cycled Ventilation

PSVPSV

Time (sec)

Flow(L/m)

Pressure(cm H2O)

Volume(mL)

Flow CyclingFlow Cycling

Set PS level

Set PS level

Patient Triggered, Flow Cycled, Pressure limited Mode

20

SIMV(Volume-Targeted Ventilation)

SIMV(Volume-Targeted Ventilation)

Spontaneous Breaths

Flow(L/m)

Pressure(cm H2O)

Volume(mL)

Pressure

Flow

Volume

(L/min)

(cm H2O)

(ml)

Set PC levelSet PC level


SIMV Mode (Pressure-Targeted Ventilation)

SIMV Mode (Pressure-Targeted Ventilation)

Spontaneous Breath

21

Pressure

Flow

Volume

(L/min)

(cm H2O)

(ml)

SIMV + PS (Pressure-Targeted Ventilation)

SIMV + PS (Pressure-Targeted Ventilation)

PS Breath

Set PS levelSet PC levelSet PC level

Time (sec)

Time-Cycled Flow-Cycled

Spontaneous Breath

Time (sec)

Flow(L/m)

Pressure(cm H2O)

Volume(mL)

22

CPAPCPAP


CPAP level

Flow

(L/m)

Pressure

(cm H2O)

Volume

(mL)

CPAP + PSVCPAP + PSV

Set PS level

CPAP level


Flow(L/m)

Pressure(cm H2O)

Volume(mL)

Flow Cycling

23

24

25

26

Components of breath delivery

Triggering Inspiration Cycling Expiration

Flow

Time

吸氣啟動吸氣啟動吸氣啟動吸氣啟動 (Trigger)

• 壓力啟動壓力啟動壓力啟動壓力啟動 (Pressure trigger)

• 氣流啟動氣流啟動氣流啟動氣流啟動 (Flow trigger)

27

Start of inhalation: Patient

trigger

Paw

Time

Pressure trigger

Flow

Time

Flow trigger

吸氣氣流的調整

• 吸氣早期

-Rise time percent

• 氣流自動調整

-Autoflow, Evita 4

28

Cycling

• Volume cycle• Pressure cycle• Time cycle• Flow cycle

29

吸氣結束(Expiratory sensitivity)

• 壓力支持型呼吸的吸氣停止多為吸

氣氣流降於起始氣流的25%

• 吐氣靈敏度即為氣流降至起始氣流

的百分比,是可以調整的

Cycling with ETS

Flow

Time

30

Effects of flow triggering on breathing effort during partial ventilatory support.

Aslanian P, El Atrous S, Isabey D, Valente E, Corsi D, Harf A, Lemaire F, Brochard L.

Am J Respir Crit Care Med. 1998 Jan;157(1):135-43.

31

-0,6

-0,4

-0,2

0

0,2

0,4

0,6

0

4

8

12

16

20

0 2 4 6 8

Ineffective Triggering

Flow (L/s)

Airway Pressure (cmH20)

Time (s)

Increase of flow

Decrease of pressure

Wasted effort

32

Kondili et coll, BJA 2003

inspiration

expiration

FR=13

FR=33

33

34

自發性呼氣末端正壓自發性呼氣末端正壓自發性呼氣末端正壓自發性呼氣末端正壓(Auto-PEEP,or Intrinsic-PEEP)

• 病患用力吐氣,氣道外壓力高於氣道內壓力

引起氣道狹窄,甚至塌陷

• 在吐完氣後,氣道仍可測得殘餘正壓

• 在吸氣時,更要費力產生負壓,以擴張塌陷的氣道

• 呼氣呼不完全,肺泡撐得較大

• 吸氣時,必須面對更大的彈性阻抗

• 吸氣作功會增加

35

36

V= 30 l/min (0,5 l/s)

V= 90 l/min (1,5 l/s)

Kondili et coll, BJA 2003

Effect of different inspiratory rise time and cycling off criteria during pressure support ventilation in

patients recovering from acute lung injury

Davide Chiumello; Paolo Pelosi; Paolo Taccone; Arthur Slutsky; Luciano Gattinoni

Crit Care Med 2003; 31:2604 –2610

37

-1,5

-1

-0,5

0

0,5

1

1,5

0

10

20

30

40

50

0 2 4 6 8

Double Triggering

Double

Triggering

Flow (L/s)

Airway Pressure (cmH20)

Time (s)

38

Flow-Volume LoopFlow-Volume Loop

Volume (ml)Volume (ml)

PEFR

FRC

Inspiration

Expiration

Flow (L/min)

Flow (L/min)

PIFR

VT

Components of Pressure-Volume Loop

Components of Pressure-Volume Loop

Volume Volume

((mLmL))

Inspiration

Expiration

PIP

VT

PPawaw (cm H(cm H22O)O)

39

HysteresisHysteresis

Volume (ml)

Pressure (cm HPressure (cm H22O)O)

Abnormal Hysteresis

Normal Hysteresis

Type of BreathType of Breath

ControlledControlled AssistedAssisted Spontaneous

PPawaw

(cm H(cm H22O)O)

I: Inspiration

E: Expiration

I E

E

I

E

I

40

Decreased ComplianceDecreased Compliance

Volu

me(m

l)


NormalNormal

PatientPatient

Increased RawIncreased Raw


Higher PTA

Normal Slope

Normal Slope

VolVol ((mLmL))

Lower

Slop

e

Lower

Slop

e

41

Inadequate Inspiratory FlowInadequate Inspiratory Flow

PPaw aw (cm H(cm H22O)O)

Volume Volume

(ml)(ml)

NormalNormal

AbnormalAbnormal

Active InspirationActive Inspiration

Inappropriate FlowInappropriate Flow

Inadequate SensitivityInadequate Sensitivity

Volume Volume

((mLmL))

PPawaw (cm H(cm H22O)O)Increased WOB

42

Air LeakAir Leak

Volume (ml)


Air Leak

Inflection PointsInflection Points

Pressure (cm H2O)

Volume (mL)

Upper Inflection Point

Lower Inflection Point

43

OverdistensionOverdistension

Volu

me (m

l)


With little or no change in VTWith little or no change in VT

Paw risesPaw rises

NormalAbnormal

44

Work of BreathingWork of Breathing

A: Resistive WorkB: Elastic Work

Pressure (cm H2O)

Volume (ml)

BBB

AAA

PEEP and P-V LoopPEEP and P-V Loop

Volume

(mL)

VT

PIPPIPPaw (cm H2O)

PEEP PEEP

45

Inflated 0

Alveolar Collapse(Reabsorption) 40-60 cmH2O

SuperimposedPressure

OpeningPressure

Consolidation ∞∞∞∞

(modified from Gattinoni))

Small AirwayCollapse

10-20 cmH2O

ARDS lung is multicompartimentalRegional Spectrum of Opening

Pressures

Vo

lum

e

Hysteresis of the P/V curve

Airway Pressure

46

Estimation of hysteresis using the PV tool 2

Estimation of hysteresis using the PV tool 2

47

Hysteresis as an index of collapse re-expansion

6 798 cmH2O.ml 25 115 cmH2O.ml

� Pressure (cmH2O)

� 0 � 10 � 20 � 30 � 40 � 50

�V

olu

me

(ml) � 0

� 500

� 1000

� 1500

� 2000

� 2500

� 3000

� Pressure (cmH2O)

� 0 � 10 � 20 � 30 � 40 � 50

�V

olu

me

(ml)

� 0

� 500

� 1000

� 1500

� 2000

� 2500

� 3000

Volume recruited by a recruitment maneuver

48

Alveolar volume change during tidal breathing

Di Rocco. Intensive Care Med 2007

Setting PEEP according to deflation PV curve

49

Hickling.

AJRCCM 2001

Alveoli with

highest closing pressure start to

collapse

Most of alveoli

collapse with indicates the

open-lung PEEP

Setting PEEP according to deflation PV curve

ASV Target Graphics Window

50

WOB as function of rate

0

0.02

0.04

0.06

0.08

0.1

0.12

0.14

0.16

0 10 20 30 40 50

Respiratory Rate in bpm

WO

B in

Jo

ule

/se

c

elastic

resist.

total

0

500

1000

1500

2000

0 20 40 60

RR (b/min)

TV

(m

L)

COPD, asthma,

emphysema

ARDS, fibrosis,

pneumonia

Adapted Support

ventilation

51

��Pinsp

��RRIMV

��Pinsp

��RRIMV

��Pinsp

��RRIMV

�� Pinsp

��RRIMV

Adaptive Support Ventilation

(Pmax-PEEP)*Cdyn

5 b/min 20/RCexp

2*Vd

NAVA Preview

52

ARDS

ARDS - Before Intervention

53

ARDS – After Recruitment

See all important information at a glance

resistance compliancetidal

volume

inspiratory

time

54

PEEP

See all important information at a glance

FiO2

FiO2 RSB%fSpontExp

MinVolPinsp

Improve SA: Inform on present status

� symmetric lung, nicely

moving

� no airway obstruction

� patient activity

� oxygenation OK

� CO2 elimination OK

� sponaneous activiy OK

55

Example ARDS� asymmetric stiff lung

� slight airway

obstruction

� no patient activity

� oxygenation not OK

� CO2 elimination not OK

� sponaneous activiy not OK

=> No alarm – patient and ventilator states are consistent

Performance of the Ventilation Cockpit

Traditional – Flow Volume Spirometry Graphic Display – Dynamic Lung

Performance with & without the Dynamic Lung from the Hamilton G5 Ventilator

Robert Albert; Noah Syroid; James Agutter; Dwayne Westenskow - Society for Technology in Anesthesia; Jan 2008

56

Thank you for

your attention

Date post:	29-Nov-2023
Category:	Documents
Upload:	khangminh22
View:	0 times
Download:	0 times

Ventilator waveform monitor and trouble shooting

Documents