graphics waveforms 2 - solutions x 2 - home or bird beak formation at the top of the loop cause -...
TRANSCRIPT
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Stanley John RT,BS,RRT-NPS,CPFT,CPC,ACCS,AE-C Assistant Director – NSUH Respiratory Therapy Department Vice Chairman – New York State Education Department (OP) - Respiratory Therapy & Polysomnography Licensure Board
Adjunct Instructor- Molloy College
Waves ! Curves! RT’s!&
Disclosure
I have no actual or potential conflict of interest in relation to this presentation!!This presentation is for informational/educational purpose only !
In the beginning there was…..!• Drager pulmotor!
Ventilator in a box!
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Non Invasive Route!
Chest Respirator ‘aka’ Chest Cuirass!
Philip Drinker & Louis Agassis Shaw Tank Respirator (1927)!
Drinker’s iron lung cost about $1,500—the average price of a home!
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John Emerson Iron Lung (1931)!
Emerson’s Iron Lung was quieter and cheaper $1000 !
1952 Polio!
Puritan Bennet MA 1 (1967)!
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Drager EV-A (1982) !
EV-A. Depiction of the ventilation curves on the integrated screen!
PB 7200 (1983)!
12!12
Puritan Bennett!PB 840!
Philips Respironics!Espirit!
Maquet!Servo 300A!
Drager!Evita Infinity!
Carefusion!Avea!
Current ICU Ventilators
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Non Acute Care Ventilators
So what's all the Fuzz?!
• We survived without monitors • Cost of the device • In the end half the therapist/clinicians
don’t know how to interpret graphs • Is it worth it??!
What does the literature say!
• Quote studies • Used more frequently in the Neo/Ped
areas • Diagnostic/trending and
troubleshooting tool • Every student, fresh grad and
practicing Rt should be competent in interpreting wave forms!
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!!
Optimizing patient-ventilator synchrony is essential in managing patients who require prolonged mechanical ventilation in the long-term acute-care hospital. Daily ventilator checks (that include calculation of the lung compliance) and the availability of pressure-volume graphs can help ensure the correct settings.!
Appropriate recognition and management of patient-ventilator asynchrony require bedside assessment of ventilator graphics as well as direct patient observation. !
David J Pierson Patient-Ventilator Interaction Respir Care, February 2011 56:2 214-228; doi:10.4187/ respcare.01115!
Jon O Nilsestuen and Kenneth D Hargett Using Ventilator Graphics to Identify Patient-Ventilator Asynchrony Respir Care, February 1, 2005 50:2 202-234 !
Maher Ghamloush, Heidi H O'Connor, and Alexander C White Patient-Ventilator Interaction in the Long-Term Acute-Care Hospital Respir Care, February 2011 56:2 207-213; doi:10.4187/respcare.01084 !
Asynchrony is an important and common problem that can occur at several points in the breathing cycle!
The Pigtail Sign On Flow Pressure Loops Is a New Way To Detect Secretions and frequency of suctioning
Rohit Goyal, MD*; Lalit Kanarparthi, MD; Murray Rogers, MD; Tarun Madappa, MD; Larry Difabrizio, MD; Klaus D. Lessnau, MD!
Understanding ventilator waveforms—and how to use them in patient care
Lian, Jin Xiong RN
Working With Respiratory Waveforms: How to Use Bedside Graphics
Burns, Suzanne M. RN, MSN, RRT, ACNP, CCRN, FAAN, FCCM
Charles G Durbin, Jr
Applied Respiratory Physiology: Use of Ventilator Waveforms and Mechanics in the Management of Critically Ill Patients Respir Care, February 1, 2005 50:2 287-293
Graphical waveforms have become ubiquitous in clinical care. Using and understanding pictures & symbols should be a daily activity that needs to be incorporated in our daily rounds
Are you convinced?!
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Like any visual picture or art.…..information about waveforms cannot easily be conveyed in words or taught in didactic lectures!
DID YOU KNOW!
Regardless of the type of mode or breath • 4 parameters will always be displayed
as scalar graph • Pressure, Volume, Flow & Time • The type of graph you select will
depend on what you are trying to monitor of trouble shoot
• 2 type of waveform graphics!
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Scalar Graph!
Time=sec!
Flow!
Pres
sure!
Volu
me!
Time=sec!
Time=sec!Inspiration!Expiration!
Inspiratory phase= Active • Affected by ventilator modes and settings Expiratory Phase= Passive • Not affected by ventilator modes* • Affected by the patients respiratory component • i.e resistance , compliance, leak *Inverse Ratio Ventilation!
OR!
cmH
20!
L/M
in!
mL!
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Ventilator Mode!
Time!
Flow!
Pres
sure!
Volu
me!
VC! VA! PS!PA!PC!
set IP!
set VT! set VT!
set Flow! set Flow!
variable IP! variable IP!
variable Flow! set min Flow!variable Flow!
variable VT! variable VT!variable VT!
Pt triggered breath! Pt triggered breath! Pt triggered breath!
set IP!
set IT!
set IP!
set IT!
Time! Time! Time! Time!
100%!75%!50%!30%!
Ventilator Mode!
Time!
Flow!
Pres
sure!
Volu
me!
NPPV! CPAP!
variable Flow! variable Flow!
variable VT! variable VT!
set IT!
set IP!
Time!
variable IP!
• Inspiratory time is shortest for square wave flow
form • Highest peak inspiratory pressures(PIP) • Low mean airway pressure (MAP) - helps with venous return and cardiac output • �Mostly use with Volume control mode • � Usually preferred as the initial flow rate since
it meets the flow demand of the patient. Decreases air hunger
• Flow waveform can be changed depending on the ventilator options!
FLOW WAVEFORM - SQUARE ! Flow!
Time!
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FLOW WAVEFORM -DESCENDING RAMP!
• Increases inspiratory time (if not fixed) or peak inspiratory flow rate (if inspiratory time is fixed)
• Least peak inspiratory pressures • Decreases expiratory time , potential for auto PEEP • Increases mean airway pressure - helps lung inflation and improves oxygenation • Always used with Pressure control mode • Similar to square wave its preferred for AC/SIMV
patients • as the initial flow rate meets the flow demand of
the patient. • Decreases air hunger!
Flow!
Time!
• Inspiratory time is the shortest • Comfortable for patient since it mimics natural breathing • Flow starvation • Low Mean Inspiratory pressure -better venous return and cardiac output • Used with CPAP /spontaneously breathing modes • � Should not be used with control/ assist modes.!
FLOW WAVEFORM :SINUSOIDAL!
Flow!
Volume!
• Longer I-Time • Initial start up flow is slow • Used with CPAP/BiPAP modes as a ramp
feature • Not recommended for patients on A/C mode • Leads to air hunger, Dy synchrony�!
FLOW WAVEFORM : Ascending Ramp!
Flow!
Time!
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Loop Graph!
Inspiration!Expiration!
Flow!
Volume!
Non intubated patient!
PEFR!
PIFR!
Flow!
Volume!
Intubated patient!
PEFR!
PIFR!VT!
FRC!VT!
Loop Graph!
Pressure!
Volu
me!
Inspiration!Expiration!
Pressure!
Volu
me!
VT!
PIP!
Flow!
Volume!
Controlled! Assisted!
Pressure!
Volu
me!
VT!
PIP!
Spontaneous!
Loop graph!
Leak ● Incomplete loop, the waveform
never returns to baseline or zero
● Cause - Et tube cuff leak, leak around area of chest tube, BP fistula, loose circuit connection
● Fix - Check the inspiratory and expiratory circuit of the ventilator, replace the ruptured Et tube or insert a bigger size
Also an indication that the prior swelling or edema has decreased!
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Loop Graph -Leak!
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Pressure!
Volu
me!
Reference!
Pressure!
Volu
me!
Inspiration!Expiration!
Scalar Graph- Leak!
Time!
Flow!
Pres
sure!
Volu
me!
Time!
Time!
Time!
Time!
Time!
Expiratory limb does not return to baseline!
Decreased expiratory flow!
Decreased pressure !
Scalar graph!
Auto PEEP ● The expiratory flow does
not return to baseline before the beginning of the next breath
● Cause - Hyperventilation which decrease E time , Short E Time,increased RAW can lead to air trapping
● Fix - Increasing expiratory time, increasing the flow and increasing PEEP/MAP!
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Loop Graph -Auto Peep!
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Pressure!
Volu
me!
Normal!
Pressure!
Volu
me!
!
0!0!5!10! 5!10!15!
Inspiration!Expiration!
Assisted Breath and WOB!
Pressure!
Volu
me!
set IP!
Pt triggered neg pressure breath!
Pres
sure!
Time!Pt triggered neg pressure breath!
PS Level during CPAP!
set IP=PS!
set min Flow!
variable VT!
Pt triggered breath!
100%!75%!50%!30%!
Inspiratory phase ends Expiration begins!
set IP=PS!
set min Flow!
variable VT!
Pt triggered breath!
75%!
Inspiratory phase ends Expiration begins!
set IP=PS!
set min Flow!
variable VT!
Pt triggered breath!
10%!
Inspiratory phase ends Expiration begins!
Flow!
Pres
sure!
Volu
me!
Time! Time! Time!
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Water/secretion in the circuit!
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Flow!
Volume! PEFR!
PIFR!
VT!FRC!
Flow!
Volume!
PIFR!
VT!
Secretion in the airway! Post suctioning!
Autotriggering can occur sometimes due to water in the tubing!
Loop graph!
Overdistension ● penguin or bird beak formation
at the top of the loop ● Cause - high Vt or Pressure ● Fix - decrease Vt or Inspiratory
preassure ● Remember VE will decrease It is a good graph to monitor the
constant change in RAW and compliance of the patient lung!
Loop graph!
Obstruction ● peaking of the loop (or a
concave area) with a decreased flow rate, increased RAW
● Cause - secretion in the airway, bronchospasm, water in the tubing, plugged airway
● Fix - Suction the patient, bronchodilator therapy,empty the codensation in the ventilator circuit!
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Scalar Graph -Bronchospasm!
Normal! Airway Resistance! Post Bronchodilator Treatment!
PEFR!PEFR!
E-Time! E-Time!E-Time!
Improved PEFR!
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Loop graph!
Compliance ● The farther the loop
moves to the right and the more horizontal it is to the pressure axis the lower the compliance of the lung
● Cause - Patients with RDS, pulmonary edema, BPD
● Fix - Surfactant replacement therapy,optimum PEEP!
Lung compliance!
Pressure!
Volu
me!
Normal!
Pressure!
Volu
me!
0!Set PIP!
Inspiration!Expiration!
> 45 = ↑ Compliance!< 40 = ↓ Compliance!
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To sum it all up!
Ventilator graphics and monitoring capabilities present RT’s with multiple opportunities to:
Ø Apply respiratory physiology at the bedside and to use them to
improve patient care and outcomes Ø Become experts in reading waveform and graphics like telemetry
staff and use it as a diagnostic tool Ø Incorporated it into your everyday practice to optimize ventilator
settings Ø Make ventilator graphics and waveforms a vital part of your
curriculum, orientation/preceptor program and daily rounds similar to chest radiograph and electrocardiogram.
Ø Use it when trouble shooting ventilator related issues
Similar to an artwork
Appreciation and understanding waveforms takes practice!
Artist: Oleg Shuplyak !
ANY QUESTIONS ?
Waves, Curves, and RTʼs!