Basic Pulmonary Mechanics during Mechanical Ventilation
Points of Discussion
Basics , scalars and loops1. Equation of motion2. Airway pressures3. Compliance4. Resistance5. Pressure-Time6. Flow-Time7. Pressure-volume loop8. Flow-volume loop9. Work of breathing10.Hysterexis
Abnormalities1. Air Leak2. Auto PEEP and air trapping3. Active Exhalation4. Inadequate insp flow5. Obstruction6. Trigger sensitivity7. Increased airway resistance 8. Inadequate flow support9. Inadequate sensitivity10.Atelectasis11.Inadequate PEEP12.Over-distension
Inspiration
Spontaneous Breathing
Exhalation
Precondition of Inspiration
• Pa < Pb– Spontaneous
breath• Pb > Pa
– Mechanical ventilation
Pb
Pa
Gas Flow
Pa < Pb
Spontaneous Inspiration
Volume Change
Gas Flow
Pressure Difference
Mechanical Ventilation
Pressure Difference
Volume Change
Gas Flow
“The Feature of the Tube”
R = D PD F
Airway Resistance
Pressure Difference = Flow Rate x Resistance of the Tube
Volume Change = Pressure Difference x Compliance of the Balloon
Volume
Pressure
D V
D P
C = D VD P
Compliance
Tube + Spring Model
Elastic Forces
Resistive Forces
Basic Calculations
Cst = dV / (Pplat-PEEP)
R = (PIP-Pplat) / Flow
dP = R x Flow + dV / C st
time
Pressure
PEEP
Pplat
elastance = Dpressure / Dvolume
volume
transairwaypressure
transthoracicpressure
transrespiratorypressure
Lung Mechanics resistance = Dpressure / Dflowflow
Pressure vs TimeSpontaneous Breath
P aw (c
m H
20)
Time (sec)
Inspiration
Expiration
Pressure vs TimeMechanical Breath
InspirationExpirationP a
w (
cm H
2O)
Time (sec)
}TI
Peak Inspiratory PressurePIP
PEEPTE
Spontaneous vs. Mechanical
Mechanical
Time (sec)
SpontaneousPaw (cm H2O)
Inspiration
ExpirationExpiration
Inspiration
Assisted vs Controlled
Time (sec)
Assisted ControlledPressure (cmH20)
Components of Inflation Pressure
Begin Expiration
P aw (
cm H
2O)
Time (sec)
Begin Inspiration
PIP
Pplateau
(Palveolar)
Transairway Pressure (PTA)}
Expiration
Inspiratory Pause
Begin Inspiration Begin Expiration
P aw (
cm H
2O)
Time (sec)
Airway Resi
stance
Distending (Alveolar)
Pressure Expiration
Inflation Hold(seconds)
Begin Expiration
P aw (
cm H
2O)
Time (sec)Begin Inspiration
PIP
Pplateau
(Palveolar
Transairway Pressure (PTA)
}Exhalation Valve Opens
Expiration
PIP
PIP vs Pplat
NormalHigh Raw
High Flow
Low Compliance
Time (sec)
Paw
(cm
H2O
)PIP
PPlat
PIP
PIP PIP
PPlatPPlat
PPlat
Mean Airway Pressure
Increase FlowIncrease peak pressureLengthen Inspiratory TimeIncrease RateIncrease PEEP
P ressure
T im e
Increasing Mean Airway Pressure
1. Increase flow2. Increase peak pressure3. Lengthen inspiratory time4. Increase PEEP5. Increase Rate
Flow vs Time
Inspiration
Expiration
Time (sec)
Flow
(L/m
in)
Flow Patterns
ACCELERATING
DECELERATING
SINE
SQUARE
Flow Patterns and Effects of Volume
ACCELERATINGDECELERATING SINESQUARE
Inspiratory Flow Pattern
Inspiration
Expiration
Time (sec)
Flow
(L/m
in)
Beginning of inspirationexhalation valve closes
Peak inspiratory flow ratePIFR
Beginning of expirationexhalation valve opens
Total cycle timeTCT
Inspiratory Time
TI
Expiratory Time TE
Expiratory Flow Pattern
Inspiration
Expiration
Time (sec)
Flow
(L/m
in)
Beginning of expirationexhalation valve opens
Peak Expiratory Flow RatePEFR
Duration of expiratory flow
Expiratory time
TE
Spontaneous Breath
Time (sec)
Flow
(L/m
in) Inspiration
Expiration
Mechanical vs Spontaneous
Inspiration
Expiration
Spontaneous
Mechanical
Increased Expiratory Resistance
Time
Flow
Normal Resistance Increased Resistance
Response to Bronchodilator
Before
Time (sec)
Flow
(L/m
in)
PEFR
After
Long TE
Higher PEFR
Shorter TE
Insufficient Expiratory Time
TimeFlow
End-Expiratory Flow
Air Trapping
Inspiration
Expiration
NormalPatient
Time (sec)
Flow
(L/m
in)
Air TrappingAuto-PEEP
}
Excessive Secretions
Inspiration
Expiration
NormalPatient
Time (sec)
Flow
(L/m
in)
Air Leak (Flow Trigger, autotriggering)
Inspiration
Expiration
Time (sec)
Flow
(L/m
in)
Leak in LPM
Active Inspiration or Asynchrony
Flow (L/min)
Time (sec)
NormalAbnormal
Patient’s effort
Excessive Inspiratory Time
Inspiration
Expiration
NormalPatient
Time (sec)
Flow
(L/m
in)
Air TrappingAuto-PEEP
}
Increase WOB and “Fighting” of the ventilator
Obstruction vs Active Expiration
Obstruction Active Expiration
Time (sec)
NormalAbnormal
Flow (L/min)
Trigger Sensitivity
Pressure
Sensitivity levelTime
Flow
Time
Volume vs. Time
Inspiration
Expiration
Time (sec)
Volu
me
(ml)
Inspiratory Tidal Volume
TI
Active Exhalation
Volume (ml)
Time (sec)
Inadequate Inspiratory Flow
Adequate Flow
Time (sec)
Inadequate Flow
P aw
(cm
H2O
)
Air LeakVo
lum
e (m
l)
Time (sec)
Air Leak
Air Leak
Expiratory flow area less than inspiratory flow area
Expired volumeInspired volume
Leak
Pressure
Flow
Volume
FRC and PV Loop
FRC
VOLU
ME
TLC
Negative Positive0
DISTENDING PRESSURE
Normal Compliance
FRC
Components of Pressure-Volume Loop
Volume (mL)
Insp
iratio
n
Expi
ratio
n
PIP
VT
Paw (cm H2O)
Pressure-Volume Loop(Type of Breath)
Controlled Assisted Spontaneous
Vol (
ml)
Paw (cm H2O)
I: Inspiration E: Expiration
I
E
E
E
II
PEEP and P-V Loop
Volume (mL)
VT
PIPPaw (cm H2O)
PEEP
Inflection Points
Pressure (cm H2O)
Volume (mL)
Upper Inflection Point
Lower Inflection Point
Upper Inflection Point: Represents pressure resulting in regional overdistension
Lower Inflection Point: Represents minimal pressure for adequate alveolar recruitment
Decreased Compliance
Volu
me(
ml)
Pressure (cm H2O)
NormalPatient
Lung Compliance Changes and the P-V Loop
Volume (mL)
PIP levels
Preset VT
Paw (cm H2O)
Normal
Volume Targeted Ventilation
Decreased
Increased
Lung Compliance Changes and the P-V Loop
Volume (mL)
Preset PIP
VT
leve
ls
Paw (cm H2O)
Normal
Pressure Targeted Ventilation
Increased
Decreased
Hysteresis
Volume (ml)
Pressure (cm H2O)
Abnormal Hysteresis
Normal Hysteresis
Flow-Volume Loop
Volume (ml)
Inspiration
Expiration
Flow
(L /
min
)
PEFR
FRC
PIFR
VT
Work of Breathing
A: Resistive Work B: Elastic Work
Pressure (cm H2O)
Volume (ml)
B
A
Work of Breathing• WOB is a major source of caloric expenditure and oxygen
consumption• Appr. 70% to overcome elastic forces, 30% flow-resistive work• Patient work is a one of the most sensitive indicator of ventilator
dependency• Comparison of Ventilator and Patient work is a useful indicator
during weaning process• WOB may be altered by changes in compliance, resistance,
patient effort, level of support, PEEP, improper Ti, demand system sensitivity, mode setting
• Elevated WOB may contraindicate the weaning process
WOB Measurements
WOB = ∫0
ti P x Vdt• Elasic work: ABCA• Resistive work
– Inspiratory: ADCA– Expiratory: ACEA
PA
B C
D
E
V
Work of Breathing Measurements
WOB = ∫0
ti P x Vdt• Paw: Ventilator Work: The physical force required to
move gas into the lung, represents the total work of the resp. system (patient + ventilator)
• Peso: Patient Work: done by respiratory muscles, represents the pulmonary work of breathing
• Paw-Ptr: Imposed Work by the Endotracheal tube
P-V Loop and WOB
P
V
P
V
P
VNormal ComplianceNormal Resistance
Normal ComplianceIncreased Resistance
Decreased ComplianceNormal Resistance
Work of BreathingWork per breath is depicted as a pressure-volume areaWork per breath (Wbreath) = P x tidal volume (VT)Wmin = wbreath x respiratory rate
Pressure Pressure Pressure
Volu
me
Volu
me
Volu
me
VT
WR = resistive work
WEL = elastic work
The total work of breathing can be partitioned between an elastic and resistive work. By analogy, the pressure needed to inflate a balloon through a straw varies; one needs to overcome the resistance of the straw and the elasticity of the balloon.
Intrinsic PEEP and Work of Breathing
Volu
me
VT
VT
FRCPressure
PEEPi
Dynamic Hyperinflation
PEEPi = intrinsic or auto PEEP; green triangle = tidal elastic work; red loop = flow resistive work; blue rectangle = work expended in offsetting intrinsic PEEP (an expiratory driver) during inflation
When present, intrinsic PEEP contributes to the work of breaking and can be offset by applying external PEEP.
++
++
Ventilator
₊ ₊
The Pressure and Work of Breathing can be Entirely Provided by the Ventilator (Passive
Patient)
The Work of Breathing can be Shared Between the Ventilator and
the Patient
PAW
PES
patient machine
time
AC mode
The ventilator generates positive pressure within the airway and the patient’s inspiratory muscles generate negative pressure in the pleural space.
Paw = Airway pressure, Pes= esophageal pressure
Work of breath
Resistive Work
Elastic Work of Lung
Elastic Work of Chest
Paw
Pes
Volume
Pres
sure
Work to inflate the chest wall
Inflation Deflation
Relationship Between the Set Pressure Support Level and the Patient’s Breathing
Effort
Carrey et al. Chest. 1990;97:150.
The changes in Pes (esophageal pressure) and in the diaphragmatic activity (EMG) associated with the increase in the level of mask pressure (Pmask = pressure support) indicate transfer of the work of breathing from the patient to the ventilator.
Partitioning of the Workload Between the Ventilator and the Patient
How the work of breathing partitions between the patient and the ventilatordepends on:
• Mode of ventilation (e.g., in assist control most of the work is usually done by the ventilator)• Patient effort and synchrony with the mode of ventilation• Specific settings of a given mode (e.g., level of pressure in PS and set rate in SIMV)
Abnormalities• Air-leak• Air trapping• Increased airway resistance • Inadequate flow support• Inadequate sensitivity• Atelectasis• Inadequate PEEP• Airway obstruction• Over-distension
Air Leak
Volume (ml)
Pressure (cm H2O)
Air Leak
Air LeakInspiration
Expiration
Volume (ml)
Flow (L/min)
Air Leak in mL
NormalAbnormal
Air TrappingInspiration
Expiration
Volume (ml)
Flow (L/min)
Does not returnto baseline
NormalAbnormal
Increased Airway ResistanceInspiration
Expiration
Volume (ml)
Flow (L/min)
Decreased PEFR
NormalAbnormal“Scooped out”
pattern
Increased Raw
Pressure (cm H2O)
Higher PTA
Normal
Slope
Vol (mL)
Lower Slope
Airway Secretions/Water in the CircuitInspiration
Expiration
Volume (ml)
Flow (L/min)
NormalAbnormal
F
VV
F
After SuctionBefore Suction
Airway Obstruction
Optimising PEEP
V
P
PEEP: 3 cmH2O
V
P
PEEP: 8 cmH2O
Inadequate Sensitivity
Volume (mL)
Paw (cm H2O)Increased WOB
Replaced FRC
P
V
Lost FRC
V
P
Atelectasis
Overdistension
Volu
me
(ml)
Pressure (cm H2O)
With little or no change in VT
Paw rises
NormalAbnormal
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