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Chapter 009

The document is a workbook answer key for Chapter 09 of Pilbeam's Mechanical Ventilation, focusing on ventilator graphics. It includes key terms, review questions, critical thinking questions, and case studies related to mechanical ventilation concepts. The content covers various aspects of ventilator waveforms, pressures, and patient interactions with ventilators.

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207 views5 pages

Chapter 009

The document is a workbook answer key for Chapter 09 of Pilbeam's Mechanical Ventilation, focusing on ventilator graphics. It includes key terms, review questions, critical thinking questions, and case studies related to mechanical ventilation concepts. The content covers various aspects of ventilator waveforms, pressures, and patient interactions with ventilators.

Uploaded by

seajay park
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd

Cairo: Pilbeam's Mechanical Ventilation, 7th Edition

Chapter 09: Ventilator Graphics

WorkBook Answer Key

KEY TERMS CROSSWORD PUZZLE

CHAPTER REVIEW QUESTIONS

1. (a) Rectangular, (b) ascending or accelerating ramp, (c) exponential rise, (d) descending
or decelerating ramp, (e) sinusoidal or sine, and (f) exponential decay.
2. The term scalar is used to identify waveforms for pressure, flow, and volume that are
graphed relative to time. The term loop is used to describe a graph of two variables other
than time, such as pressure-volume and flow-volume loops.

Copyright © 2020 by Elsevier, Inc. All Rights Reserved.


WorkBook Answer Key 9-2

3. VT = Flow × TI.
4. The flow of gas into the lungs is dependent on (a) the difference between the pressure
from the ventilator (power source) and (b) the pressure inside the lungs.
5. Decreases (drops); increases (rises).
6. PTA (transairway pressure) + PA (alveolar pressure)
7. When the flow is constant.
8. TI = Volume ÷ Flow. Flow of 60 L/min = 60 L ÷ 60 sec = 1 L/sec. Volume of 600 mL =
0.6 L; therefore, TI = 0.6 L/1 L/sec = 0.6 second.
9. PA = ΔV ÷ Cs = 800 mL ÷ 25 mL/cm H2O = 32 cm H2O
10. (a) Inspiration begins, (b) inspiration ends, and (c) maximum or peak expiratory flow
11. Sinusoidal
12. 45 L/min
13. 50 L/min
14. 1 second
15. 2 seconds
16. Air trapping and hyperinflation
17. No. An intrinsic PEEP measurement would not be valid if the patient were actively
attempting to take a breath during the maneuver. (An unstable expiratory pause
invalidates the measurement.)
18. Intrinsic PEEP is measured at the end of exhalation.
19. Active inspiration by the patient in a ventilator that responds to patient flow demand.
20. 1-2 cm H2O
21. Sensitivity (pressure trigger) and flow settings
22. Changing the flow pattern during volume ventilation changes the pressure patterns.
23. 45 cm H2O
24. Descending or decelerating ramp; 40 L/min
25. 600 mL
26. CSTAT = ΔV ÷ (Pplateau  PEEP) = 600 mL ÷ (20  0) = 30 mL/cm H2O
27. Raw = (PIP  Pplateau) ÷ Flow = (45  20) ÷ 0.67 L/sec = 37.3 cm H2O/L/sec
28. There is no intrinsic PEEP.
29. The flow rate drops to zero before the end of inspiration, because there is an inspiratory
pause where there is no flow. After the inspiratory pause the gas is exhaled, giving the
negative appearance on the graph.
30. During decreases in lung compliance, the delivered tidal volume decreases in PC-CMV.
31. Flow returns to zero when the alveolar pressure becomes equal to the set pressure during
PC-CMV.
32. Descending ramp or exponential decay, which varies with the patient’s lung
characteristics.
33. The largest pressure gradient occurs at the beginning of inspiration.
34. Pressure, sensitivity, rise time or slope, and flow cycle time.
35. VC-SIMV (no pressure support). Look closely at the pressure waveform. It has a peak as
opposed to a flat top, and the two mechanical breaths do not have the same peak
inspiratory pressure. This means that the pressure is variable. In volume control, the
volume is set and the pressure is determined by lung characteristics.
36. PC-SIMV with CPAP and pressure support.

Copyright © 2020 by Elsevier, Inc. All Rights Reserved.


WorkBook Answer Key 9-3

37. “A” is a pressure-supported breath with a set pressure of 20 cm H2O. “B” is a pressure-
controlled breath with a set pressure of 38 cm H2O.
38. During inspiration, ATC augments flow. During expiration, it provides a slight negative-
pressure gradient between the lungs and the upper airways.
39. Peak flow rate × Flow cycling percentage = Flow rate when cycling occurs. 45 L/min ×
0.25 = 11 L/min.
40. TI = 1 second
41. 45 L/min
42. 10 L/min
43. (Ending flow ÷ Peak inspiratory flow) × 100 = Flow-cycling percentage; therefore, (10 ÷
45) × 100 = 22%.
44. 40 L/min
45. Patients with COPD have increased airway resistance and therefore need a long
expiratory time to exhale. During normal inspiration, flow drops toward the end of
inspiration. Percent flow cycling sets up a criterion to determine when inspiration will
end for a pressure-supported breath. Therefore, when inspiratory flow tapers down to that
set percentage of the peak inspiratory flow, inspiration ends. Patients with increased
airway resistance require longer times for exhalation. A higher flow cycle percentage
ends the inspiration sooner than does a lower flow cycle percentage, giving the patient a
longer time for exhalation.
46. A patient with reduced compliance fills the lungs quickly but with less volume than
normal. To allow more volume to enter the lungs for the given pressure, a lower flow
cycle percentage should be set.
47. (18 ÷ 40 L/min) × 100 = 45%
48. 200 mL
49. (5 ÷ 38 L/min) × 100 = 13%
50. 400 mL
51. “A” TI = approximately 0.75 second and “B” TI = approximately 1.25 second
52. The flow cycle percentage was lowered, increasing the inspiratory time.
53. “A” is PEEP +5 cm H2O; “B” is peak alveolar pressure; and “C” is peak inspiratory
pressure.
54. 35 cm H2O
55. 500 mL
56. There is +5 cm H2O PEEP.
57. More pressure is needed to deliver the set volume; therefore, the height of the loop
(volume) remains the same, but the loop extends farther to the right and tends to flatten
out.
58. Because the pressure remains constant, the loop will reach the same pressure but will be
shorter because less volume is being delivered to the patient for each breath.
59. Airway resistance increases because of bronchospasm, secretions in the airway, or
mucosal edema.
60. Loop “A” represents a spontaneous breath.
61. Loop “A” has a clockwise direction because a spontaneous breath is negative on
inspiration and becomes positive on exhalation.
62. Loop “B” represents a patient-triggered mandatory breath.

Copyright © 2020 by Elsevier, Inc. All Rights Reserved.


WorkBook Answer Key 9-4

63. Loop “B” has a counterclockwise direction because after the initial negative deflection
caused by the patient, the ventilator delivers the positive-pressure breath (doing all the
work).
64. 45 L/min = 0.75 L/sec, Raw = PTA ÷ Flow; 3 cm H2O ÷ 0.75 L/sec = 4 cm H2O/L/sec.
65. Hysteresis
66. This loop moves in a clockwise direction.
67. Constant flow or rectangular waveform
68. (a) 50 L/min and (b) 55 L/min
69. 425 mL
70. Either a leak in the patient (bronchopleural fistula) or a leak in the patient circuit.
71. Air trapping or the presence of intrinsic PEEP.

CRITICAL THINKING QUESTIONS

Refer to Figure 9-13 of the Workbook to complete this exercise.


1. VC-CMV. Constant flow waveforms are associated with volume control. The pressure
curves all have peaks, meaning that the pressure is not being maintained.
2. The patient is not assisting. There are no downward deflections below baseline on the
pressure scalar.
3. Total cycle time = 1.5 second. TI = 1 second. TE = 0.5 second. Set rate = 40 breaths/min.
4. The peak inspiratory pressure is increasing with each breath.
5. (1) The exhaled volume is decreasing with every breath and (2) inspiration is beginning
before all the volume has been exhaled.
6. Each breath begins before exhalation is complete. Exhalation should return to zero on the
x-axis before the beginning of the next breath.
7. Rising PIP, dropping exhaled tidal volumes, inspiration beginning before the completion
of exhalation, and an inverse I:E ratio all mean that air is being trapped in the lungs. In
this case, it is due to the rapid set rate.
8. Decrease the set rate to allow for adequate expiratory time.

CASE STUDIES

Case Study 1

1. This loop is wider because of the increased airway resistance associated with COPD. The
axis of the loop is more upright, which is a result of an increase in static compliance in
the patient’s lungs.
2. Yes, the patient is triggering the ventilator. The small loop to the left of the volume axis
on the pressure scale represents patient effort to trigger the ventilator.
3. Approximately 650 mL
4. Approximately 23 cm H2O
5. The patient has a combined alkalosis from acute alveolar hyperventilation superimposed
on chronic hypercapnic respiratory failure. The current tidal volume setting is 12 mL/kg.
This is too high; it should be reduced to deliver between 6 and 8 mL/kg, which would
give a volume between 330 and 436 mL.

Case Study 2

Copyright © 2020 by Elsevier, Inc. All Rights Reserved.


WorkBook Answer Key 9-5

1. Spontaneous breath
2. Inspiration
3. Expiration
4. Clockwise
5. There is no set pressure support. If pressure support were present, the loop would be
shifted to the positive side of the x-axis.
6. VC-CMV (or the mechanical breath during VC-SIMV). A pressure-controlled breath
would have a flatter top.
7. Yes, the patient is triggering the breath. There is a negative deflection along the x-axis, or
pressure axis.
8. Adjust the ventilator sensitivity to be more sensitive to the patient.
9. The type of flow waveform (constant), the peak inspiratory flow (50 L/min), the peak
expiratory flow (50 L/min), and the tidal volume (650 mL).
10. The current loop has a scooped-out appearance on the flow side.
11. This is due to increased airway resistance. The most likely cause, in this case, is
bronchospasm and/or increased airway secretions.
12. Aerosolized bronchodilator and tracheobronchial suctioning.

NBRC-STYLE QUESTIONS

1. A
2. C
3. C
4. B
5. C
6. B
7. A
8. C
9. D
10. B

Copyright © 2020 by Elsevier, Inc. All Rights Reserved.

Common questions

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Waveforms in mechanical ventilation, such as rectangular, ramp, sinusoidal, or exponential, influence the pressure, flow, and volume characteristics of ventilation, impacting patient comfort and ventilation effectiveness. For example, a descending ramp flow pattern can lead to lower peak pressures, potentially improving patient-ventilator synchrony and reducing the risk of barotrauma .

Altering the flow pattern in volume ventilation changes the dynamic pressure patterns experienced by the patient. For instance, switching to a decelerating ramp flow can decrease peak inspiratory pressure and improve gas exchange, while maintaining the same tidal volume, thus altering both mean airway pressure and patient comfort. Such changes must be carefully evaluated for their impact on ventilation efficiency and patient response .

Dynamic ventilation parameters like inspiratory-to-expiratory (I:E) ratio, flow rate, and tidal volume play critical roles in preventing air trapping in patients with high airway resistance. A longer expiratory time achieved through a lower respiratory rate or adjusted I:E ratio helps ensure complete exhalation. Managing peak inspiratory flow and setting appropriate flow cycle percentages can also minimize the risk of air trapping .

Increased static lung compliance in COPD implies that the lungs can hold more volume for a given pressure, allowing for more efficient gas exchange. However, it also indicates a loss of elastic recoil, which may impede adequate expiration and increase the risk of air trapping and dynamic hyperinflation, necessitating careful monitoring and adjustment of ventilation settings .

Proper sensitivity settings ensure that the ventilator appropriately responds to patient-initiated breaths, promoting synchrony and reducing patient effort. Improper settings can result in delayed triggering, patient discomfort, increased work of breathing, and potential for auto-triggering or missed breaths, impacting overall ventilation effectiveness .

Airway resistance during mechanical ventilation is quantified as the difference in pressure between the proximal airway and alveoli, divided by flow rate (Raw = PTA ÷ Flow). Factors such as bronchospasm, airway secretions, and mucosal edema can increase airway resistance, thus requiring more pressure to maintain the same flow .

Adjusting the flow cycle percentage directly impacts when inspiration ends in PSV. A lower percentage prolongs inspiratory time, potentially enhancing tidal volume and improving alveolar ventilation, whereas a higher percentage shortens inspiratory time, facilitating more complete exhalation. This adjustment is crucial for matching patient demand and preventing issues such as air trapping in conditions like COPD .

In volume control modes, peak inspiratory pressure variations are typically influenced by changes in airway resistance and lung compliance. Increased airway resistance or decreased lung compliance requires higher pressures to deliver the set tidal volume, thus altering the pressure waveform .

Intrinsic PEEP, also known as auto-PEEP, is the pressure remaining in the lungs at the end of expiration due to incomplete exhalation. It is measured at the end of exhalation, and its presence can be indicated by a rise in alveolar pressure that does not return to baseline. Its assessment is invalid if the patient attempts to inhale during the maneuver, as active inspiration distorts the measurement .

Indicators of bronchospasm or increased airway resistance on ventilator graphs include increased peak inspiratory pressure, scooped-out appearance on flow-volume loops, and delayed return to baseline on pressure-time graphs. These changes signify elevated work of breathing and reduced expiratory flow due to narrowed airways or obstruction within the lung .

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