Waveforms RC 270
Pressure Volume Curves Graphic display of changes in compliance and resistance Used for TREND analysis! – One set of waveforms must be compared to another set Pressure is on the x-axis; volume on the y- axis Separate curves for static and dynamic
Static Curve If static curve shifts, than static compliance and elastic resistance have changed – Plateau pressure also will change A change in the static curve causes the dynamic curve to shift also – Just as a plateau pressure change also affects peak pressure Rightward shift: decreased static compliance and increased elastic resistance Leftward shift: increased static compliance and decreased elastic resistance
Dynamic Curve Is affected by both elastic and airway resistance If the dynamic curve shifts, but the static curve doesn’t, than only airway resistance has changed – Rightward means increased airway resistance – Leftward means decreased airway resistance
When to plot P-V Curves Initiation of CMV Q 8-12 PRN – Change in patient status – After any therapeutic intervention
P-V Loop: Overdistension (Hyperinflation)
Flow-Time Curve: Air Trapping (AutoPeep)
Continuous Positive Pressure Breathing Breathing at a baseline airway pressure that is greater than ambient
Types of CPPB Positive End Expiratory Pressure (PEEP) – When patient is on CMV Continuous Positive Airway Pressure – When patient is breathing without CMV
Indication for PEEP/CPAP: Refractory Hypoxemia PaO2
Refractory Hypoxemia Usually Indicates Alveolar Instability Decreased surfactant Increased interstitial pressure Nitrogen washout Oxygen toxicity
Alveolar Instability Atelectasis Decreased FRC Increased shunting Decreased static compliance (increased elastic resistance) Increased W.O.B.
PEEP/CPAP Airway pressure does not drop to ambient Helps stabilize alveoli and small airways
Without PEEP/CPAP
With PEEP/CPAP PEEP/CPAP acts like a “splint” to stabilize alveoli/airways
PEEP/CPAP EFFECTS II ncreases FRC back towards normal DD ecreases shunt II ncreases static compliance (decreases elastic resistance) DD ecreases W.O.B. AA cceptable PaO2 at lowest possible FIO2
PEEP/CPAP Precautions
Potential Side Effects Increased mean intrathoracic pressure (ITP) – Hemodynamic compromise Decreased venous return Decreased cardiac output Decreased blood pressure Increased intracranial pressure (ICP) – Pulmonary baro/volutrauma – Fluid retention If PEEP/CPAP is indicated and applied appropriately, these effects should be minimized
PEEP/CPAP Precautions Unilateral lung disease Neuro patients COPD
PEEP/CPAP Controversy Classical indication: increased elastic resistance Controversy: Increased airway resistance too?
Can we please take a break!
PEEP/CPAP Systems: Flow Resistor
PEEP/CPAP Systems: Threshold Resistor
Selecting a PEEP/CPAP Level Random – Start at 5 cmH2O and watch PaO2 Optimal/Best -Set PEEP/CPAP 2 cmH2O greater than lower inflection point (LIP or Pflex) on P-V curve Best/Optimal PEEP alternative – Peep only—use PEEP level that gives best static compliance
LIP or Pflex LIP
Best PEEP always occurs at the lowest /\ P Remember /\P is gauge plateau pressure minus the peep
What if more than one PEEP level gives the same highest Cstat? Look at blood pressure Look at PvO2 Look at C.O. Look at %shunt Look at mixed venous saturation Look at P/F ratio – PaO2 divided by FIO2 (expressed in decimal form)
Recruitment Maneuver Also known as Open Lung Tool A Sustained Maximal Inspiration (SMI) performed after optimal/best PEEP/CPAP has been determined and set Example: 40 cmh2o of CPAP applied for 40 seconds (the 40/40 technique)
PEEP/CPAP works best for diseases that cause increased elastic resistance May be of help in diseases with increased airway resistance
Lets see what we can dig up