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WaveformMonitoringoftheMechanicallyVentilatedPatientTimOp’tHolt,Ed.D.,R.R.T.ProfessorCardiorespiratoryCareUniversityofSouthAlabamaObjectivesDescribethevolume,pressureandflowversustimescalars.Describetheuseofscalarsinthemanagementofthemechanicallyventilatedpatient.Describetheflow-volumeandpressure-volumeloopsastheyareusedinthemechanicallyventilatedpatient.DescribehowloopsareusedtodiagnoseandmanageproblemsinpatientsreceivingmechanicalventilationMonitoringTechniquesUsedDuringMechanicalVentilationVentilatorwaveformspressure,volumeandflowvstimescalarsflow-volumeandpressurevolumeloopsAllowsanalysisofauto-PEEP,bronchodilatorresponse,workofbreathing,hyperexpansion,adequacyofflow,ventilatorsensitivity,compliance,andleaksVentilatorWaveformsScalarsVolumeversustimePressureversustimeFlowversustimeLoopsFlow-VolumePressure-VolumeFlowversusTimeFlowversusTimeACCELERATINGACCELERATINGACCELERATINGACCELERATINGDECELERATINGDECELERATINGDECELERATINGDECELERATINGSINESINESINESINESQUARESQUARESQUARESQUAREVolumevsTimeVolumevsTimeInspirationInspirationExpirationTime(sec)Time(sec)Volume(ml)Volume(ml)InspiratoryTidalVolumeTTIIPressureversusTimePressureversusTimeInspirationExpirationPaw(cmH2O)Time(sec)}}TIPeakInspiratoryPressurePIPPEEPPEEPTEPressure-VolumeLoopPressure-VolumeLoopControlledAssistedSpontaneousVol(ml)Paw(cmH2O)I:InspirationE:ExpirationIEEEIIFlow-VolumeLoopFlow-VolumeLoopVolume(ml)Volume(ml)PEFRFRCInspirationExpirationFlow(L/min)Flow(L/min)PIFRVTAirTrappingAirTrappingInspirationExpirationNormalNormalPatientPatientTime(sec)Flow(L/min)AirTrappingAuto-PEEP}AirTrappingAirTrappingInspirationExpirationVolume(ml)Volume(ml)Flow(L/min)DoesnotreturnDoesnotreturntobaselinetobaselineNormalAbnormalPaw(cmHPaw(cmH22O)O)NormalNormalPPlat(NormalCompliance)IncreasedPIP}IncreasedPTA(increasedAirwayResistance))NormalNormalPIPPIPPPPlatPlatHighRHighRawawPIPPIPPPPlatPlatIncreasedAirwayResistanceResponsetoBronchodilatorResponsetoBronchodilatorBeforeTime(sec)Flow(L/min)PEFRAfterLongTEHigherPEFRShorterTEIncreasedRawIncreasedRawPressure(cmPressure(cmHH22O)O)HigherPTANormalSlopeNormalSlopeVol(mL)Vol(mL)LowerSlopeLowerSlopeIncreasedAirwayResistanceIncreasedAirwayResistanceInspirationExpirationVolumeVolume(ml)(ml)Flow(L/min)DecreasedPEFRNormalNormalAbnormal“Scoopedout”patternWorkofBreathingWorkofBreathingA:ResistiveWorkB:ElasticWorkA:ResistiveWorkB:ElasticWorkPressure(cmH2O)Volume(ml)BBBBAAAAOverdistensionOverdistensionVolume(ml)Pressure(cmHPressure(cmH22O)O)WithlittleornochangeinVTWithlittleornochangeinVTPawrisesPawrisesNormalAbnormalInadequateInspiratoryFlowAdequateFlowTime(sec)InadequateFlowPaw(cmH2O)InadequateInspiratoryFlowInadequateInspiratoryFlowFlow(L/min)Time(sec)NormalAbnormalActiveInspirationorActiveInspirationorAsynchronyAsynchronyPatient’seffortInadequateInspiratoryFlowInadequateInspiratoryFlowPPawaw(cm(cmHH22O)O)VolumeVolume(ml)(ml)NormalAbnormalActiveInspirationActiveInspirationInappropriateFlowInappropriateFlowInadequateSensitivityInadequateSensitivityVolumeVolume(mL)(mL)PPawaw(cmH(cmH22O)O)IncreasedWOBDECREASEDCOMPLIANCEDECREASEDCOMPLIANCETime(sec)Paw(cmH2O)LowCompliancePIPPPlatNormalNormalPIPPPlatNormalPPlat(NormalCompliance)IncreasedPPlat(DecreasedCompliance))NormalPIPLungComplianceChangesandtheP-VLoopLungComplianceChangesandtheP-VLoopVolume(mL)Volume(mL)PresetPIPVTlevelsPPawaw(cmH(cmH22O)O)COMPLIANCEIncreasedNormalDecreasedCOMPLIANCEIncreasedNormalDecreasedPressureTargetedVentilationAirLeakAirLeakVolume(ml)Volume(ml)Time(sec)Time(sec)AirLeakAirLeakAirLeakAirLeakVolume(ml)Pressure(cmHPressure(cmH22O)O)AirLeakAirLeakAirLeakInspirationExpirationVolume(ml)FlowFlow(L/min)(L/min)AirLeakinmLNormalAbnormalProblemswithWaveformsTendtobemorequalitativethanquantitativeWetendtolookatthem,butnotusethemastherapeuticordiagnostictoolsItisnotknownifpassiveflow-volumeloopsaccuratelycorrelatewithfindingsfromforcedvitalcapacityflowvolumeloopsPaucityofliteraturesubstantiatingtheirvalue