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Ruben D Restrepo, MD, RRT, FAARC Professor

Ventilator Graphics: Not Just Pretty Lines. Ruben D Restrepo, MD, RRT, FAARC Professor The University of Texas Health Science Center at San Antonio. Objectives. Identify graphic display options provided by mechanical ventilators. Describe how to use graphics to

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Ruben D Restrepo, MD, RRT, FAARC Professor

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  1. Ventilator Graphics: Not Just Pretty Lines Ruben D Restrepo, MD, RRT, FAARC Professor The University of Texas Health Science Center at San Antonio

  2. Objectives • Identify graphic display options provided by mechanical ventilators. • Describe how to use graphics to • more appropriately adjust the patient ventilator interface.

  3. Introduction • Monitoring and analysis of graphic display of curves and loops during mechanical ventilation has become critical to determine • how patient is being ventilated • to assess problems occurring during ventilation

  4. Uses of Flow, Volume, and Pressure Graphic Displays • Confirm mode functions • Detect auto-PEEP • Determine patient-ventilator synchrony • Assess and adjust trigger levels • Measure the work of breathing • Adjust tidal volume and minimize overdistension • Assess the effect of bronchodilator administration

  5. Uses of Flow, Volume, and Pressure Graphic Displays • Detect equipment malfunctions • Determine appropriate PEEP level • Evaluate adequacy of inspiratory time in pressure control ventilation • Detect the presence and rate of continuous leaks • Assess inspiratory termination criteria during Pressure Support Ventilation • Determine appropriate Rise Time

  6. Mechanical Ventilation Graphics SCALARS LOOPS

  7. SCALARS Flow/Time Pressure/Time Volume/Time

  8. LOOPS Pressure-Volume Flow-Volume

  9. SCALARS Flow/Time Pressure/Time Volume/Time

  10. Spontaneous Breath Inspiration Time (sec) Flow (L/min) Expiration

  11. Mechanical Breath Inspiration Time (sec) Flow (L/min) Expiration

  12. Typical Flow Patterns SQUARE DECELERATING ACCELERATING SINE

  13. Total cycle time TCT Inspiratory Flow Pattern Beginning of expiration exhalation valve opens Peak inspiratory flow rate PIFR Inspiration Expiratory Time TE Insp. time TI Flow (L/min) Time (sec) Beginning of inspiration exhalation valve closes Expiration

  14. Beginning of expiration exhalation valve opens Duration of expiratory flow Peak Expiratory Flow Rate PEFR Expiratory Flow Pattern Inspiration Expiratory time TE Time (sec) Flow (L/min) Expiration

  15. Inspiratory Pause Inspiration pause Time (sec) } Flow (L/min) Expiration

  16. Patient’s effort Inadequate Inspiratory Flow Active Inspiration Normal Abnormal Time (sec) Flow (L/min)

  17. Air Trapping Auto-PEEP Normal Patient Air Trapping Inspiration Time (sec) Flow (L/min) } Expiration

  18. Response to Bronchodilator After Before Time (sec) Flow (L/min) Long TE PEFR Shorter TE Higher PEFR

  19. SCALARS Flow/Time Pressure/Time Volume/Time

  20. Inspiratory Tidal Volume Volume vs Time Volume (ml) Inspiration Expiration TI Time (sec)

  21. Volume lost Air Leak/Air Trapping Volume (ml) Time (sec)

  22. SCALARS Flow/Time Pressure/Time Volume/Time

  23. Spontaneous Breath Expiration Paw (cm H20) Time (sec) Inspiration

  24. Peak Inspiratory Pressure PIP PEEP Mechanical Breath Paw (cm H2O) Inspiration Expiration TI TE } Time (sec)

  25. CONTROLLED BREATH (Time Triggered) Mechanical Paw (cm H2O) Time (sec) Time Triggered Breath

  26. Assisted Breath(Patient Triggered) Mechanical Paw (cm H2O) Time (sec) Patient Triggered Breath

  27. Assisted vs Controlled Assisted Controlled Pressure (cmH20) Time (sec)

  28. Spontaneous vs. Mechanical Mechanical Inspiration Paw (cm H2O) Spontaneous Expiration Expiration Inspiration Time (sec)

  29. Exhalation Valve Opens Pplateau (Palveolar) Begin Inspiration Components of Inflation Pressure PIP } Transairway Pressure (PTA) Paw (cm H2O) Inspiratory Pause Expiration Time (sec) Begin Expiration

  30. Inadequate Inspiratory Flow Inadequate Flow Adequate Flow Paw (cm H2O) Time (sec)

  31. LOOPS Pressure-Volume Flow-Volume

  32. Pressure-Volume Loop(Type of Breath) E E Vol (ml) I E I I Paw (cm H2O) Spontaneous Controlled Assisted I: Inspiration E: Expiration

  33. Components of Pressure-Volume Loop VT Expiration Volume (mL) Inspiration PIP Paw (cm H2O)

  34. VT PEEP PIP PEEP and P-V Loop Volume (mL) Paw (cm H2O)

  35. Work of Breathing Volume (ml) B A: Resistive Work B: Elastic Work A Pressure (cm H2O)

  36. Upper Inflection Points Lower Inflection Point Inflection Points Volume (mL) Pressure (cm H2O)

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

  38. Air Leak/Air Trapping Volume (ml) Air Leak Pressure (cm H2O)

  39. Inadequate Inspiratory Flow Volume (ml) Active Inspiration Inappropriate Flow Normal Abnormal Paw (cm H2O)

  40. Increased Raw Higher PTA Volume (ml) Higher PTA Paw (cm H2O)

  41. Hysteresis Volume (ml) Normal Hysteresis Abnormal Hysteresis Pressure (cm H2O)

  42. Lung Compliance Changes and the P-V Loop Volume Targeted Ventilation Preset VT COMPLIANCE Increased Normal Decreased Volume (mL) Paw (cm H2O) PIP levels

  43. Lung Compliance Changes and the P-V Loop COMPLIANCE Increased Normal Decreased VT levels Pressure Targeted Ventilation Volume (mL) Preset PIP Paw (cm H2O)

  44. Overdistension With little or no change in VT Normal Abnormal Volume (ml) Pressure (cm H2O) Paw rises

  45. LOOPS Pressure-Volume Flow-Volume

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

  47. Air Leak Inspiration Flow (L/min) Volume (ml) Air Leak in mL Normal Abnormal Expiration

  48. Air Trapping Inspiration Flow (L/min) Does not return to baseline Volume (ml) Normal Abnormal Expiration

  49. Increased Airway Resistance Inspiration Flow (L/min) Volume (ml) Normal Abnormal “Scooped out” pattern Decreased PEFR Expiration

  50. Airway Secretions/Condensate in the Circuit Inspiration Flow (L/min) Volume (ml) Normal Abnormal Expiration

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