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vent graphics in PICU

vent graphics

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vent graphics in PICU

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  1. vENTILATOR GRAPHICS IN PICU ….. Optimizing Ventilation DrVishramBuche Central India’s CHILD hospital & Research institute, NAGPUR Part 1……..

  2. How to identify different WAVES and LOOPS ? and thereby mode of vent ? How it helps to monitor Ventilator parameters ? How it helps to adjust vent settings/ parameters ? How it helps to identify / quantify the problem? How it helps to manage disease pattern ? OBJECTIVES…… • GOAL ……. • 1. Reduce WOB, Optimize ventilation • & Improve patient comfort • 2. Maximize therapeutic effect • 3. Minimize ventilator associated lung injury

  3. PARAMETERS…………

  4. MEASUREMENT OF FLOW…….

  5. MEASUREMENT OF PRESSURE ………. At ETT Where it is measured…. ? In esophagus Inside Ventilator Inside the Pt’s airway ……..???

  6. Basic phase variables………….. A. Trigger ……. • What causes the breath to begin? B. Limit ………. • What regulates gas flow during the breath? • C. Cycle ……… • What causes the breath to end? D. Baseline…… End exp Pressure (FRC level) B C D A

  7. The Pulmonary graphics display in two formats……… Scalars…… Loops……... Basic shapes….. Square, Sine and Exponential rise or decay

  8. Mechanical Breaths…. Spontaneous Breaths…. volume Time Pressure FLOW

  9. Pressure Modes Volume Modes Pressure Flow Volume Time

  10. Pressure waveform used to access…… Volume Modes Pressure Modes • Breath type • Triggering • I:E ratio • PIP/Plateau pressure • MAP • PEEP • Active exhalation • Auto-PEEP • Airway obstruction • Bronchodilator response • Compliance/Raw • Asynchrony Pressure Flow Volume Time

  11. Flow waveform used to access……… Pressure mode volume mode • I:E ratio • Breath type • Inspiratory flow rate (set/PIF) • Rise time • Auto-PEEP • Airway obstruction • I-Time adjustment • Active exhalation • Bronchodilator response • Asynchrony F time

  12. Volume waveform used to access……… Pressure mode Volume mode • I:E • Tidal volume • Auto-PEEP • Active exhalation • Air-leak • Airway resistance • Asynchrony Time

  13. Loops…….

  14. P-V loop F-V loop Flow Inspiration PIFR expiration Volume PIP Volume VT FRC inspiration PEFR Expiration 5 15 30 Pressure Breath type Tidal volume PIP I & E flow rate Resistance Compliance Asynchrony Air leaks secretions

  15. Graphic analysis to optimize ventilation…..

  16. Common causes of Pt-vent asynchrony…………….. • Tidal volumes too low • Inspiratory flow too slow • Inspiratory time too long • Trigger sensitivity too negative • Increased resistance of ETT • AutoPEEP • Pain, discomfort and agitation

  17. Pressure wave………… Effect of ed air way resistance/compliance PIP PIP P plat P plat

  18. Pressure wave………… Effect of Auto-PEEP.... Air-trapping…..Auto-PEEP While performing an expiratory hold maneuver, trapped air will cause the waveform to rise above the baseline.

  19. Clinical signs of AUTOPEEP………… • Tachypnoea ....earliest sign • Appearance of s/o resp distress • With present vent setting like • Accessory muscles usage, intercostal • retractions etc • Rising PaCO2 is a late sign

  20. I Rise time……. How do I adjust it? P 0 time F 0 time

  21. I Rise time…….fast Bart simpson spike Rise time “overshoots” Desired pressure time Too fast

  22. I Rise time…….fast “SPIKE ” on graphics IRT is set at 0.05 seconds

  23. I Rise time…….fast Increase IRT…………….. …..waveform will return to normal

  24. I Rise time…….slow P 0

  25. Inspiratory rise time is directly Proportionalto inspiratory flow to getproportional Vt is deliverd

  26. PRESSURE waveform……… To Increase Mean Airway Pressure…. 1. Increase flow 2. Increase peak pressure 3. Lengthen inspiratory time 4. Increase PEEP 5. Increase Rate MAP….. PIP     Pressure  PEEP Ti TE Time

  27. Flow waveform…… Effects of  airway resistance/ obstruction PIF PEF TV In severe insp airway obstruction, the wave form can become a plateau. This can become a problem in flow-cycled modes, such as Pressure Support. (asynchrony, W.O.B.)

  28. Flow waveform…… Effects of ed expiratory resistance

  29. Normal Patient Air Trapping……… AUTO PEEP Flow waveform…… Inspiration Time Flow (L/min) Air-trapping AUTO PEEP Expiration

  30. Response to Bronchodilator…. Flow waveform…… Before After Long TE Normal TE Flow Time  PEFR Improved PEFR To assess response to bronchodilator therapy,…. 1. An increase in peak expiratory flow rate. 2. The expiratory curve should return to baseline sooner.

  31. 3 2 1 . V 1 2 3 Bronchodilator Response….. F-V loop AFTER Relief Bronchospasm Normal 3 3 2 2 1 1 . . V LPS VT V 1 1 2 2 3 3

  32. Assessing Bronchodilator Therapy…… • Optimizing Auto –PEEP……

  33. Flow waveform…… Inspiratory flow pattern…… I –time synchrony 1 2 1 : short 2 : Normal 3 : Prolonged 3 Asynchrony leads to……. Low tidal volume delivery Auto-PEEP

  34. Setting Appropriate I-Time ………. ……to get desired V T = 25 PCV…. PIP= 20, Vt (achieved) = 18 18 cc volume 0 1 2 3 4 5 6 Time Flow 1 2 3 4 5 6 Time Short I – time ……low Vt

  35. Setting Appropriate I-Time ………. 18 cc 25 cc volume 0 1 2 3 4 5 6 Lost VT Flow 4 1 2 3 5 6 Time Appropriate I – time ……good Vt

  36. Adjusting I-time……… Inspiratory Cycle off %............................ flow cycling 100% 75% 50% 30% 25%

  37. Inspiratory Cycle off %............................ flow cycling 60% time time

  38. Inspiratory Cycle off %............................ flow cycling Exhalation “spike” 10% time time

  39. Flow time wave……. F Secretions Or water in circuit

  40. VOLUME waveform……………….. Increased Airway resistance Exhaled vol taking longer time to reach baseline Time Exhaled volume takes longer time to return to baseline ……… damp or blocked expiratory filter/valve

  41. Air trapping / Air Leak………… VOLUME waveform……………….. Volume (ml) Air Leak Exhalation side of the waveform doesn’t return to baseline, it could be 1---- air-trapping (improperly set I-time, emphysema), 2---- air leak (ET tube, vent circuit, chest tube, etc.) And can lead to auto-triggering Time (sec)

  42. Air Leak…… VOLUME waveform……………….. P-V loop Volume waveform…. V 30 F-V loop F VT ml P V -10

  43. Air-trapping….. Resolved….. NOT all Air-trapping ……… is Pathological……..

  44. Air Trapping….. P-V loop and F-V loop Exp Insp PIFR Flow volume VT • Insp Exp Pressure PEFR • The expiratory portion of the loop doesn’t return to baseline. • This indicates a air trapping/or air leak.

  45. Air trapping on Loops……

  46. At 1st session of vent graphics class…… MY MOM-IN-LAW BENDING OVER! A HORSIE A DUCKY! No A DOGGIE

  47. Volume waveform … trending..guides for weaning PCV… SIMV A….Ineffective tidal volume in spontaneous breaths; B….Improved tidal volume during spontaneous breaths.

  48. Loops……. Pressure-Volume Loops Flow-Volume Loops

  49. P-V loops…… • Lung Overdistention • Airway Obstruction • Bronchodilator Response • Respiratory Mechanics • WOB • Flow Starvation • Leaks • Triggering Effort

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