Stepwise Ventilator Waveform Assessment To Diagnose Pulmonary Pathophysiology
Stepwise Ventilator Waveform Assessment To Diagnose Pulmonary Pathophysiology
Stepwise Ventilator Waveform Assessment To Diagnose Pulmonary Pathophysiology
, Editor
This article has been selected for the Anesthesiology CME Program. Learning objectives and disclosure and ordering information can be found in the CME section at the front of
this issue. This article is featured in “This Month in Anesthesiology,” page A1.
Submitted for publication December 17, 2021. Accepted for publication March 25, 2022. Published online first on May 5, 2022.
Brigid C. Flynn, M.D.: Department of Anesthesiology, Division of Critical Care, University of Kansas Health Systems, Kansas City, Kansas.
Haley G. Miranda, M.D.: Department of Anesthesiology, Division of Critical Care, University of Kansas Health Systems, Kansas City, Kansas.
Aaron M. Mittel, M.D.: Department of Anesthesiology, Division of Critical Care, Columbia University Irving Medical Center, New York, New York.
Vivek K. Moitra, M.D., M.H.A., F.C.C.M.: Department of Anesthesiology, Division of Critical Care, Columbia University Irving Medical Center, New York, New York.
Copyright © 2022, the American Society of Anesthesiologists. All Rights Reserved. Anesthesiology 2022; 137:85–92. DOI: 10.1097/ALN.0000000000004220
underlying lung physiology. In the absence of patient effort, Prolonged expiratory time constants (more than 0.7 s
expiration is a passive process that reflects the resistive and with an expiratory flow time of more than 2.5 s) should
elastic loads of the respiratory system. Passive expiratory prompt bedside clinicians to hypothesize that lung com-
flow waveforms demonstrate exponential decay to base- pliance is high (e.g., in chronic obstructive pulmonary dis-
line as thoracic elastic recoil forces air out of the lung until ease [COPD]) or airway resistance is elevated (e.g., mucous
PEEP is reached (fig. 1A).4 This period is especially useful plugging, kinked endotracheal tube, bronchial resistance).
for the bedside clinician who is attempting to generate a In these instances, the expiratory time constant will be pro-
hypothesis of intrinsic pulmonary pathophysiology, as this longed and expiratory peak flow will be reduced during
passive period reflects the influence of variables on the right passive exhalation (fig. 1B).5,6 In patients who have a high
side of the equation of motion only. resistive load (e.g., bronchospasm), use of bronchodilators
may increase the peak expiratory flow rate and shorten the
Step 1: Assess Expiratory Flow Waveform to Generate a time for flow to return to baseline.
Fig. 1. Expiratory flow waveforms (bold lines) in volume control ventilation. Note that the expiratory portion of the waveforms would be
similar in pressure control ventilation. PEEP, positive end-expiratory pressure.
evaluation of the patient’s respiratory effort and receipt of central airways. This rapid expulsion leads to a reduction in
sedatives or paralytics.8 Inspiratory patient effort during expiratory flow from the other airways and regional vol-
expiration is identified on the expiratory waveform by the utrauma. In contrast to auto-PEEP from a short expira-
movement of flow upwards, toward baseline (fig. 1F). An tory time, expiratory flow limitation does not respond to
upward deflection without a subsequent inspiratory breath prolonging expiratory time or reducing respiratory rate.10
may also represent a failed trigger, an autotrigger (see the If PEEP is reduced to 0, flow increases in normal lung
sections “Failure to Trigger” and “False Triggering”), or zones but decreases in zones with expiratory flow limita-
relaxation of expiratory effort. An upward deflection that tion. Increasing external PEEP can alleviate intrinsic PEEP
occurs immediately after an inspiratory cycle suggests a during expiratory flow limitation.
premature cycle (patient inspiratory effort beyond the set Secretions. Hypothesize the presence of airway secretions
inspiratory time) to expiration (fig. 1F). Expiratory effort or condensate in the ventilator circuit when faced with a
during expiration is characterized by the movement of flow sawtooth expiratory flow (fig. 1H).
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CLINICAL FOCUS REVIEW
increased compliance (COPD) and increased airway resis- the independent variable, and the flow waveform is the
tance are lower, and time constants are prolonged. Flow may dependent variable.
not reach baseline because the lung inflates slowly (fig. 2F). Calculate the Plateau Pressure and the Driving Pressure. Plateau
In lung units with prolonged inspiratory time constants pressure (Pplat) reflects lung compliance and can be calcu-
(i.e., bronchospasm), alveolar inflation time is prolonged, lated in both volume control ventilation and pressure con-
and tidal volumes may be reduced if inspiratory time is trol ventilation. Calculating plateau pressure during pressure
not increased. Conversely, the hypothetical presence of low control ventilation is important when resistive load is high
compliance states can be corroborated by the observation or inspiratory time is short. Plateau pressure is assessed at
of short inspiratory time constants and decreased insuffla- end inspiration with the inspiratory hold maneuver, when
tion times (fig. 2G). alveolar and circuit pressure have reached equilibration
If the decelerating flow waveform has a linear or upward (fig. 3A). The difference between peak inspiratory flow
concavity shape (vs. an exponential decay), inspiratory (PIP) and Pplat reflects airway resistance. Escalating [PIP
patient effort is likely, and inspiratory pressures or flow may – Pplat] values suggest resistive pathologies such as mucus
be inadequate (fig. 2H). Shortening the rise time or the plugging, bronchospasm, or circuit obstruction (fig. 3B).
time to achieve a target pressure can manage inadequate Increased Pplat, indicative of poor compliance, suggests
flow. A leak or an increase in flow from lung recruitment ARDS, pulmonary edema, pneumonia, or pneumothorax
also shifts the waveform upwards. (fig. 3C). Additionally, auto-PEEP in the setting of bron-
chospasm is associated with elevated plateau pressures and
Step 3: Assess Inspiratory Pressure Curves to Confirm an increased [PIP – Pplat] (fig. 3D). Perform a static expira-
Pathophysiologic Diagnosis tory hold maneuver to measure the presence of auto-PEEP,
which may influence compliance measurements.
Flow is the independent variable controlled by the ven- Volume Control: Pressure Waveform with Square Flow. Flow
tilator in volume control ventilation, and assessing the is controlled by the ventilator after the clinician selects the
dependent pressure waveform can confirm the pathophys- desired volume in volume control ventilation. Assessing the
iologic hypothesis generated by analysis of the expiratory resulting pressure waveform can confirm the pathophysiol-
flow waveform. In contrast to volume control ventilation, ogy hypothesis. The initial rise in pressure reflects the resis-
the pressure waveform of pressure control ventilation is tive load in a passive patient. The end inspiratory pressure is
a function of the elastic load in the airways. In contrast to initial portion of the pressure curve is flat and then appears
volume control ventilation, inspiratory pressure waveforms scooped as the breath is delivered, compliance decreases and
add little information to inspiratory flow waveform analysis overdistention is likely (upward concavity; stress index or
during pressure control ventilation. With constant flow in b > 1.05; fig. 3G). The pressure waveforms of a patient with
a passive patient, the slope of the pressure curve (after the overdistended alveoli or a patient with an active inspiratory
initial rise in pressure) reflects lung compliance. effort in the setting of inadequate flow are similar with an
The stress index is derived from the airway pressure– upward concavity (fig. 3H). Distinguish overdistension from
time curve (Paw – t) and has been validated to assess com- active effort by observing the patient at the bedside and not-
pliance by quantifying recruitment and overdistention ing the presence or absence of a patient-triggered breath.14
during square waveform flow.11,12 The shape of the airway Volume Control: Pressure Waveform with Decelerating
pressure–time curve with constant inspiratory flow is related Flow. Switching the ventilator from a square to a descending
to compliance and is represented by the equation: flow waveform in volume control ventilation may reduce
the effect of increased airway resistance and peak inspiratory
P = a * tb + c (4)
aw pressure. Additionally, decelerating flow waveforms decrease
where a is the slope of curve of steady flow between time0 peak inspiratory pressures, dead space ventilation, the A-a gra-
and time1, c is the Paw at time0, and b (stress index) is a dient, and potentially patient respiratory effort by increasing
dimensionless number that describes the shape of the curve. mean airway pressures and improving patient-to-ventilator
Experimental models and clinical trials have suggested synchrony.15 Switching from a square waveform to a decel-
that a stress index of 0.95 to 1.05 is ideal. This calculated erating flow waveform may increase inspiratory time unless
value is not commonly available on most anesthesia ven- the flow rate is increased, predisposing patients to reduced
tilators but can be reliably assessed with visual analysis of expiratory times and potential auto-PEEP.When inspiratory
the ventilator Paw – t.13 If the slope is linear (stress index flow is delivered in a descending pattern, the initial pres-
or b =1) throughout inspiration, compliance is linear and sure rise is from the resistive load in a passive patient and is
reflects noninjurious alveolar distention (fig. 3E). If compli- also reflected at end inspiration by the difference between
ance is worse at the beginning of the breath and improves the peak and plateau pressures (fig. 4A). This initial rise is
as the lung recruits, the inspiratory pressure curve bows out higher with increased resistive load. A high initial rise with
(downward concavity: stress index or b < 0.95; fig. 3F). If the a significant drop in the pressure waveform to a lower end
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Flynn et al. 2022; 137:85–92 89
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CLINICAL FOCUS REVIEW
inspiratory pressure once the flow reaches 0 can confirm of typically 1 to 2 cm H2O of patient effort (represented
the presence of a resistive lung load (bronchospasm; fig. 4B). by a negative deflection in the pressure waveform; fig. 4A)
As flow descends to 0, the pressure waveform reflects the or a change in the continuous flow of the circuit (often
plateau pressure, such that the end of inspiratory pressure represented by a change in color of the initial portion of
with descending flow reflects elastance. Patients with a high inspiratory flow; fig. 2, B and D). Identifying a patient-
elastic load (low compliance) will see an elevated pressure at triggered breath and a passive or machine-triggered breath
the end of inspiration as the flow reaches 0 (fig. 4C). Poor can unmask pathology in the presence of patient effort. If
lung compliance should be distinguished from exhalation both breaths are identical, there is no Pmus. A deep and wide
during a mechanical inspiratory breath, which also increases negative deflection of pressure during the trigger phase
pressure at the end of inspiration (fig. 4D). suggests a strong respiratory drive. Triggering asynchronies
Volume Control: Inspiratory Patient Effort. Pressure waveforms reflect either an absence of ventilator response, known as
can provide evidence of patient effort. If the patient is actively “failure to trigger,” or an absence of patient effort, known
Fig. 4. Pressure waveforms in volume control ventilation with a descending waveform flow pattern (A to E, H); cardiac oscillations during
expiratory flow waveform (F); and double triggering with inspiratory flow waveform (G). PEEP, positive end-expiratory pressure.
pressure because alveolar pressure must still be overcome in airway pressure late in the machine-delivered inspiratory
to negative to initiate flow into the lungs (as described in cycle suggest this dyssynchrony (fig. 4G). As for premature
the equation of motion).18 cycling, correct delayed cycling by modifying inspiratory
False Triggering (Autotriggering). False triggering or auto- time to match the patient’s desired inspiratory length more
triggering occurs when the ventilator provides a breath in precisely, in this case, by shortening the machine’s inspira-
response to a stimulus unrelated to patient effort. Entities tory epoch.21
such as cardiac oscillations, condensation in ventilator tub- Early Trigger or Reverse Trigger. With an early or
ing, continuous negative flow from the ventilator circuit or reverse trigger, a reflexive inspiratory effort follows a
chest tube leaks, highly sensitive (easy) triggering thresh- machine-triggered breath (fig. 4H). When coupled with
olds, or external vibrations (i.e., renal replacement therapy, inspiratory cycles over time, this phenomenon is referred
chest tube, gastric suction tubing) can cause deflections in to as “entrainment.” It typically occurs near the transi-
pressure and flow that are interpreted by the ventilator as tion from the inspiratory to the expiratory phase. Reverse
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