Basic Pulmonary Mechanics during
Mechanical Ventilation
MAZEN KHER ALLAH, MD, MHA, F C CP
Points of Discussion
BASICS , SCALARS AND LOOPS ABNORMALITIES
Equation of motion ◦ Air Leak
◦ Auto PEEP and air trapping
Airway pressures
◦ Active Exhalation
Compliance ◦ Inadequate insp flow
Resistance ◦ Obstruction
◦ Trigger sensitivity
Pressure-Time ◦ Increased airway resistance
Flow-Time ◦ Inadequate flow support
Pressure-volume loop ◦ Inadequate sensitivity
◦ Atelectasis
Flow-volume loop ◦ Inadequate PEEP
Work of breathing ◦ Over-distension
Hysterexis
Spontaneous Breathing
Exhalation
Exhalation Inspiration
Inspiration
Precondition of Inspiration
Pa < Pb
Pa < Pb
Pb
◦ Spontaneous
breath
Gas Flow
Pb > Pa
◦ Mechanical
ventilation
Pa
Spontaneous Inspiration
Volume Change
Pressure Difference
Gas Flow
Mechanical Ventilation
Pressure Difference
Gas Flow
Volume Change
Airway Resistance
“The Feature of the Tube”
D P
R= D F
Pressure Difference = Flow Rate x Resistance of the Tube
Compliance
D V
Volume
C=D P
DV
DP
Pressure
Volume
VolumeChange
Change==
Pressure
PressureDifference
Difference xx Compliance
Complianceofofthe
theBalloon
Balloon
Tube + Spring Model
Resistive Forces
Elastic Forces
Basic Calculations
dP = R x Flow + dV / C st
Pressure
Cst = dV / (Pplat-PEEP)
R = (PIP-Pplat) / Flow
Pplat
PEEP
time
resistance = Dpressure / Dflow
Lung Mechanics
flow
transairway
pressure
transrespiratory
pressure
transthoracic
volume pressure
elastance = Dpressure / Dvolume
Pressure vs Time
Spontaneous Breath
Expiration
Paw (cm H20)
Time (sec)
Inspiration
Pressure vs Time Mechanical Breath
Peak Inspiratory Pressure
PIP
Paw (cm H2O)
Inspiration
Expiration
TI TE
} PEEP
Time (sec)
Spontaneous vs. Mechanical
Mechanical
Inspiration
Paw Spontaneous
(cm H2O) Expiration
Expiration
Inspiration
Time (sec)
Assisted vs Controlled
Pressure Assisted Controlled
(cmH20)
Time (sec)
Components of Inflation Pressure
PIP
Paw (cm H2O)
Transairway Pressure
Inspiratory Pause
Pplateau
Expiration
Time (sec)
Start of Inspiration Start of Expiration
PIP
Paw (cm H2O)
} Transairway
(P )
Pressure
TA Exhalation Valve Opens
Pplateau
(Palveolar
Expiration
Time (sec)
Begin Inspiration Begin Expiration
PIP Inflation Hold
(seconds)
Paw (cm H2O)
n ce
si sta Distending
R e
way (Alveolar)
r
Ai Pressure Expiration
Time (sec)
Begin Inspiration Begin Expiration
PIP vs Pplat
PIP
High Raw
PIP Normal
PPlat PPlat
Paw (cm H2O)
PIP PIP Low Compliance
PPlat
High Flow
PPlat
Time (sec)
Mean Airway Pressure
Lengthen
Increase
Increase
Increase
Increase
Inspiratory
peak
PEEP
Rate
pressure
FlowTime
Increasing Mean Airway Pressure
P re s s u re
1. Increase flow
2. Increase peak pressure
3. Lengthen inspiratory time
4. Increase PEEP
5. Increase Rate
T im e
Flow vs Time
Inspiration
Flow (L/min)
Time (sec)
Expiration
Flow Patterns
SQUARE DECELERATING
ACCELERATING SINE
Flow Patterns and Effects of Volume
SQUARE DECELERATING ACCELERATING SINE
Inspiratory Flow Pattern
Beginning of expiration
Peak inspiratory flow rate exhalation valve opens
PIFR
Inspiration
Flow (L/min)
Inspiratory
Time Expiratory Time
TI TE
Time (sec)
Beginning of inspiration
exhalation valve closes Expiration Total cycle time
TCT
Expiratory Flow Pattern
Beginning of expiration
exhalation valve opens
Inspiration Expiratory
time
TE
Flow (L/min)
Time (sec)
Duration of
expiratory flow
Expiration
Peak Expiratory Flow Rate PEFR
Spontaneous Breath
Inspiration
Flow (L/min)
Time (sec)
Expiration
Mechanical vs Spontaneous
Mechanical
Spontaneous
Inspiration
Expiration
Increased Expiratory Resistance
Flow
Time
Normal Resistance Increased Resistance
Response to Bronchodilator
Before After
Flow (L/min)
Time (sec)
Long TE
PEFR
Shorter TE
Higher
PEFR
Insufficient Expiratory Time
Flow Time
End-Expiratory
End-Expiratory Flow
Flow
Air Trapping
Inspiration
Normal
Patient
Flow (L/min)
Time (sec)
}
Air Trapping
Auto-PEEP
Expiration
Excessive Secretions
Inspiration
Normal
Patient
Flow (L/min)
Time (sec)
Expiration
Air Leak (Flow Trigger, autotriggering)
Inspiration
Flow (L/min)
Time (sec)
Leak in LPM
Expiration
Active Inspiration or Asynchrony
Patient’s effort
Normal
Abnormal
Time (sec)
Flow
(L/min)
Excessive Inspiratory Time
Inspiration
Normal
Increase WOB and “Fighting” of the ventilator
Patient
Flow (L/min)
Time (sec)
}
Air Trapping
Auto-PEEP
Expiration
Obstruction vs Active Expiration
Obstruction Active Expiration
Time (sec)
Flow
(L/min)
Normal
Abnormal
Trigger Sensitivity
Pressure
Time
Sensitivity level
Flow
Time
Volume vs. Time
Inspiratory Tidal Volume
Volume (ml)
Inspiration
Expiration
TI
Time (sec)
Active Exhalation
Volume (ml)
Time (sec)
Inadequate Inspiratory Flow
Adequate Flow Inadequate Flow
(cm H2O)
Paw
Time (sec)
Air Leak
Volume (ml)
Air Leak
Time (sec)
Air Leak
Pressure
Flow
Expiratory flow area less
than inspiratory flow area
Inspired volume Expired volume
Volume
Leak
FRC and PV Loop
Normal Compliance
TLC
VOLUME
FRC
FRC
Negative 0 Positive
DISTENDING PRESSURE
Components of Pressure-Volume Loop
VT
n
tio
ra
pi
Ex
Volume
(mL)
n
tio
i ra
sp
In
Paw (cm H2O) PIP
Pressure-Volume Loop
(Type of Breath)
E
E
Vol (ml)
I E
I I
Paw
(cm H2O)
Controlled Assisted Spontaneous
I: Inspiration E: Expiration
PEEP and P-V Loop
VT
Volume
(mL)
PEEP
Paw (cm H2O) PIP
Inflection Points
Upper Inflection Point:
Upper Inflection Point
Represents pressure
resulting in regional
overdistension
Lower Inflection Point:
Represents minimal
pressure for adequate
Volume (mL)
alveolar recruitment
Lower Inflection Point
Pressure (cm H2O)
Decreased Compliance
Normal
Patient
Volume(ml)
Pressure (cm H2O)
Lung Compliance Changes and the P-V
Loop
Volume Targeted Ventilation
Preset VT
Increased
Increased
Normal
Normal
Decreased
Decreased
Volume (mL)
Paw (cm H2O)
PIP levels
Lung Compliance Changes and the P-V
Loop
VT levels
Pressure Targeted Ventilation
Increased
Normal
Normal
Decreased
Decreased
Volume (mL)
Paw (cm H2O) Preset PIP
Hysteresis
Volume (ml)
Normal Hysteresis
Abnormal Hysteresis
Pressure (cm H2O)
Flow-Volume Loop
Inspiration
PIFR
Flow (L/min)
Volume (ml)
FRC VT
PEFR
Expiration
Work of Breathing
Volume (ml)
A: Resistive Work
B: Elastic Work
A
Pressure (cm H2O)
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 V
Resistive work B C
◦ Inspiratory: ADCA
◦ Expiratory: ACEA
D
A P
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
V
Normal Compliance Decreased Compliance
Increased Resistance Normal Resistance
P
V V
Normal Compliance
Normal Resistance
P
P
Work of Breathing
Work per breath is depicted as a pressure-volume area
Work per breath (Wbreath) = P x tidal volume (VT)
Wmin = wbreath x respiratory rate
WEL = elastic work
WR = resistive
Volume
Volume
Volume
work
VT
Pressure Pressure Pressure
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
When present, intrinsic PEEP contributes to the work of breaking and
can be offset by applying external PEEP.
Volume
VT
VT
Dynamic
FRC Hyperinflation
Pressure
PEEPi
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
The Pressure and Work of Breathing can be
Entirely Provided by the Ventilator (Passive
Patient)
Ventilator
+ +
₊ + + ₊
The Work of Breathing can be Shared
Between the Ventilator and the Patient
The ventilator generates
positive pressure within the
airway and the patient’s AC mode
inspiratory muscles generate
negative pressure in the
PAW
pleural space.
patient machine
PES
time
Paw = Airway pressure, Pes= esophageal pressure
Work of breath
Resistive Work
Elastic Work of Lung
Pressure
Elastic Work of Chest
Paw
Pes
Work to inflate the chest wall
Inflation Deflation
Volume
Relationship Between the Set Pressure Support
Level and the Patient’s Breathing Effort
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.
Carrey et al. Chest. 1990;97:150.
Partitioning of the Workload Between the
Ventilator and the Patient
How the work of breathing partitions between the patient and the ventilator
depends 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)
Air Leak
Pressure (cm H2O)
Air Leak
Inspiration
Flow
(L/min)
Volume (ml)
Air Leak in mL
Normal
Abnormal
Expiration
Air Trapping
Inspiration
Flow
(L/min)
Does not return
to baseline
Volume (ml)
Normal
Abnormal
Expiration
Increased Airway Resistance
Inspiration
Flow
(L/min)
Volume (ml)
Normal
“Scooped out”
pattern Abnormal
Decreased PEFR
Expiration
Increased Raw
Higher PTA
Vol (mL)
p e
Slo
a l
m
N or e
l o p
r S
w e
Lo
Pressure (cm H2O)
Airway Secretions/Water in the Circuit
Inspiration
Flow
(L/min)
Volume (ml)
Normal
Abnormal
Expiration
Airway Obstruction
F F
V V
Before Suction After Suction
Optimising PEEP
V V
P P
PEEP: 3 cmH2O PEEP: 8 cmH2O
Inadequate Sensitivity
Volume
(mL)
Paw (cm H2O)
Increased WOB
Atelectasis
Lost FRC Replaced FRC
V V
P
P
Overdistension
With
With little
little or
or no
no
change in
change in VTTV
Normal
Abnormal
Volume (ml)
Pressure (cm H2O) P
Paw rises
aw rises
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