CHAPTER 28

WAVE FORM ANALYSIS

INTRODUCTION
The capability to track airway pressures, volumes, and flows graphically during mechanical ventilation of the
patient has been available for some time (BEAR, 1987). The most recent acute care ventilators have expanded
this graphical monitoring capability beyond pressure, volume, and flow to include combinations of these
reflecting air trapping, work of breathing, airway resistance, and other clinical problems and variables relating
to ventilation. The method of wave form analysis can be applied for rapid, real-time assessment of the patient-
ventilator system, providing important information regarding changes in the patient’s status. As a respiratory
care practitioner, you must be able to utilize this information at the bedside in the care of your patients.
In this chapter you will learn how to interpret pressure, volume, flow, pressure-volume, and flow-volume wave
forms. You will learn how this information can assist you in adjusting ventilator flow, sensitivity, and pressure
and in determining the patient’s work of breathing, airway resistance, compliance, and other clinical variables.

KEY TERMS
• Air trapping • Plateau pressure • Static pressure

THEORY
OBJECTIVES
At the end of this chapter, you should be able to: • Analyze a flow versus time wave form and identify
• Differentiate among the following wave forms: the following:
— Pressure versus time — Inspiratory flow pattern
— Volume versus time — Inspiration and expiration
— Flow versus time — Air trapping
— Pressure versus volume — Increased airway resistance
— Flow versus volume • Analyze a volume versus time wave form and
• Differentiate among the following wave form identify the following:
morphologies: — Inspiration versus expiration
— Rectangular — Tidal volume
— Accelerating — Air trapping
— Decelerating — Spontaneous and ventilator or mandatory
— Sinusoidal breaths
— Oscillating
• Analyze a pressure versus time wave form and
• Analyze a volume versus pressure wave form and
identify the following:
identify the following:
— Inspiration versus expiration
— Inspiration and expiration
— Tidal volume
— PEEP
— Inspiratory work
— Patient effort
— Overdistention
— Peak pressure
— Increases or decreases in compliance
— Plateau or static pressure
— Increases or decreases in airway resistance
— Inadequate inspiratory flow
— Spontaneous breaths and inspiratory effort • Analyze a flow versus volume wave form and
— Ventilator or mandatory breaths identify changes in airway resistance.

all three wave forms to analyze what occurred at that

COMMON WAVE FORMS moment in time (see Figure 28-1). This information is pre-
Three wave forms are typically presented together on the sented by most ventilators on a real-time, breath-by-breath
same screen or page with most acute care ventilators. basis.
These wave forms include pressure, flow, and volume Other wave forms are pressure versus volume and flow
(Figure 28-1). All of these wave forms plot the variable— versus volume wave forms.
pressure, flow, or volume—versus time. At any point The pressure versus volume wave form is illustrated in
along the time axis, a vertical line can be projected through Figure 28-2. Notice that the volume versus pressure wave

643
644 • CHAPTER TWENTY-EIGHT

IngMar Medical Adult/Pediatric Lung Model: Settings C=n/s, R=1, no leaks IngMar Medical Adult/Pediatric Lung Model: Settings C=n/s, R=1, no leaks
80 80
Flow (L/min)

40
0 60
2 4 6 8 10 12 14
–40
–80 40
Pressure (cm H2O)

20
16
20
12

Flow (L/min)
8
Volume (ml)
4 0
0 200 400 600 800 1000 1200
2 4 6 8 10 12 14
800 –20
Volume (ml)

600
400 –40
200 Time
(seconds)
0 –60
2 4 6 8 10 12 14

Figure 28-1 The standard display of pressure, flow, and volume ver-
sus time. Note how a vertical line projected through each wave form –80
allows visualization of what occurred at that moment.
Figure 28-3 A flow versus volume loop. Flow is plotted on the ver-
tical axis, while pressure is plotted on the horizontal axis.

IngMar Medical Adult/Pediatric Lung Model: Settings C=n/s, R=1, no leaks

800
WAVE FORM MORPHOLOGIES
The shape of a wave form may be classified as rectangular,
accelerating, decelerating, sinusoidal, or oscillating (White,
600 1999; Chatburn, 1991). These wave form morphologies are
illustrated in Figure 28-4. These wave form shapes are usu-
ally observed in evaluating the flow versus time graphic.
The shape is often determined by the drive mechanism of
Volume (ml)

the ventilator, or the flow pattern setting (White, 1999).

400

ANALYSIS OF SPECIFIC WAVE FORMS

200
Pressure versus Time
The pressure versus time graphical display is very helpful
in answering many clinical questions. Pressure rises from
baseline to the peak pressure value during inspiration and
Pressure (cm H2O) then falls to baseline again during exhalation (Figure 28-5).
0 Addition of positive end expiratory pressure (PEEP) raises
0 5 10 15 20
the baseline pressure to the PEEP level. Observation of this
Figure 28-2 Volume versus pressure wave form. Volume is plotted graphical display allows determination of patient effort,
on the vertical axis, while pressure is plotted on the horizontal axis. peak and plateau pressures, adequacy of inspiratory flow,
and mandatory (ventilator) versus spontaneous breath types.
Patient effort may be evaluated by observing for the
form makes a loop. This presentation of data is helpful pressure to fall below the baseline level (Figure 28-6). With
in assessing compliance, airway resistance, and work of pressure triggering, the ventilator initiates inspiration in
breathing. Interpretation of these specifics is described response to a pressure drop detected by a transducer
later in this chapter. (Chatburn, 1991; Nilesestuen & Hargett, 1996). If the pres-
The flow versus volume wave form also makes a loop, as sure drop is large, the sensitivity may be set too high and
illustrated in Figure 28-3. Flow-volume loops are common should be readjusted to reduce the patient’s work of
in pulmonary function application. The flow-volume loop breathing. Reduced patient effort will be evident by a
is helpful in detecting changes in airway resistance. smaller pressure drop to initiate inspiration.
Changes in this graphical display may be observed before Peak pressure and static or plateau pressure may be
and after administration of bronchodilators. evaluated by assessing the pressure versus time graphical
 WAVE FORM ANALYSIS • 645

Resource Resource

(cm H2O) (cm H2O) (C)

(A)
70
60 60
50 50

40 40
30 30
20 20
10 10

1 2 3 4 1 2 3 4
Seconds Seconds

Resource Resource
(B) (D)
(cm H2O) (cm H2O)

60 60

50 50

40 40

30 30

20 20

10 10

1 2 3 4 1 2 3 4
Seconds Seconds

Figure 28-4 Wave form morphologies: rectangular, accelerating (A), decelerating (B), sinusoidal (C), oscillating (D)

IngMar Medical Adult/Pediatric Lung Model: Settings C=n/s, R=1, no leaks IngMar Medical Adult/Pediatric Lung Model: Settings C=n/s, R=1, no leaks
20 20

16 16
Pressure (cm H2O)

Pressure (cm H2O)

12 12
(A)
(B)
8 8
(C)
4 4

0 0
0 2 4 6 0 2 4 6

Figure 28-5 A pressure versus time graphical display. Note inspi- Figure 28-6 A pressure versus time graphical display illustrating
ration (A) and expiration (B). With the addition of PEEP (C), the inspiratory effort. Note how the pressure falls below the baseline level.
baseline pressure changes, reflecting the PEEP level.

display (Figure 28-7). The peak pressure is the highest inspiratory pause, stopping flow at the end of inspiration,
pressure attained for a given breath during inspiration. By the plateau pressure may be measured. The plateau pres-
reading the maximum pressure reached on the pressure sure occurs following the peak pressure and is usually
scale, this pressure may be determined. By adding a slight lower (see Figure 28-7).
646 • CHAPTER TWENTY-EIGHT

plateau pressure with varying inspiratory times. The pres-

30 sure level (peak value) remains constant, while the inspi-
(A) ratory time varies. Pressure-controlled breaths maintain a
(B) constant inspiratory pressure and inspiratory time.
Paw Spontaneous breaths without pressure support display
cm H2O smaller variable pressure curves during exhalation and
SEC shorter pressure drops during inspiration.
1 2 3 4 5 6 Figure 28-10 shows a combination of mandatory (ven-
-10
tilator) breaths with spontaneous breaths during synchro-
Figure 28-7 The peak (A) and plateau (B) pressures may be inter- nized intermittent mandatory ventilation (SIMV) without
preted by assessing the pressure versus time graphical display. pressure support. Note the variable nature and smaller
pressure changes during the spontaneous breaths. The
mandatory breaths display a smoother pressure rise to a
Adequacy of inspiratory flow may be determined by much higher pressure level.
assessing the rise on the pressure versus time graphical
display during inspiration (Figure 28-8). If the pressure
rises slowly, or if the curve shows signs of concavity, flow Flow versus Time
is inadequate for the patient’s demand. Flow should be The flow versus time graphical display is helpful in assess-
increased, to reduce the patient’s work of breathing. ing the inspiratory flow pattern, air trapping, and airway
Breath type can be identified by observing the pressure resistance. Flow rises above baseline during inspiration
versus time morphology or shape (Figure 28-9). Pressure and falls below baseline during exhalation (Figure 28-11).
support breaths may be identified by their rise to a set Careful study of this wave form will help in assessing
many different clinical situations.
The inspiratory flow pattern or morphology may be
IngMar Medical Adult/Pediatric Lung Model: Settings C=n/s, R=1, no leaks easily assessed using the flow versus time graphical display.
20 Figure 28-12 illustrates the different types of inspiratory
flow patterns. Many of these flow patterns are generated
16
Pressure (cm H2O)

(A) according to the drive mechanism for the particular venti-

12 (B) lator (sinusoidal, for example). Most contemporary ven-
tilators allow the operator to select the desired inspiratory
8 flow pattern, and then the microprocessor alters the venti-
lator’s output to match the selected flow pattern.
4

0
0 2 4 6
IMV
PRESSURE

Figure 28-8 Note how the change in peak flow setting (B) caused
AIRWAY

the pressure to rise more quickly than it did in (A).

MACHINE
BREATHS

0–
30
(A) TIME
PLATEAU SPONTANEOUS
BREATHS

Paw Figure 28-10 Spontaneous and mandatory breath delivery during

cm H2O (B) (B)
SEC SIMV
1 2 3 4 5 6
-10
IngMar Medical Adult/Pediatric Lung Model: Settings C=n/s, R=1, no leaks

30 80

PLATEAU
40
Flow (L/min)

(A)
Paw 0
cm H2O (B)
SEC
1 2 3 4 5 6 –40
-10

–80
Figure 28-9 The type of breath may be determined by observing the
0 2 4 6
pressure versus time morphology: pressure-supported breaths (A),
pressure-controlled breaths (B). Figure 28-11 A flow versus time graphical display. Inspiration (A)
is above baseline, while expiration (B) is below baseline.
 WAVE FORM ANALYSIS • 647

Flow Flow
(L/min) (L/min)

40 (A) 40 (B)
30 30
20 20
10 10

1 2 3 4 1 2 3 4
10 Seconds 10 Seconds
20 20
30 30
40 40

Flow Flow
(L/min) (L/min)

40 40
(C) (D)
30 30
20 20
10 10

1 2 3 4 1 2 3 4
10 Seconds 10 Seconds
20 20
30 30
40 40

Figure 28-12 Inspiratory flow patterns: rectangular (A), accelerating (B), decelerating (C), and sinusoidal (D).

Air trapping, or “auto PEEP,” may be detected by fail- of the lungs to empty prior to delivery of the next breath
ure of the expiratory flow pattern to reach baseline (zero) causes an increased baseline pressure or PEEP. Sometimes,
prior to delivery of the next breath (Figure 28-13). Failure air trapping is intentional—for example, during pressure-
controlled inverse ratio ventilation (PCIRV). Other times,
the presence of auto PEEP is not intentional. Reducing the
IngMar Medical Adult/Pediatric Lung Model: Settings C=n/s, R=3, no leaks ventilatory rate (allowing for more expiratory time) may
resolve the air trapping and allow flow to reach zero before
40
the next breath is delivered.
Airway resistance may be assessed by observing the
20 slope of the expiratory flow tracing. A lower slope (smaller
Flow (L/min)

angle) is indicative of higher resistance to expiratory flow,

0 while a steeper slope (greater angle) is indicative of lower
resistance to expiratory flow (Figure 28-14). The patient’s
response to bronchodilators may be assessed by observing
–20
the flow versus time graphical display before and after
bronchodilator administration. If the slope changes
0 2 4 6
(increases) and expiratory time decreases, the patient has
Figure 28-13 Air trapping or auto PEEP. Notice how the expira- responded positively with decreased airway resistance
tory flow never reaches zero prior to the next breath being delivered. (Puritan-Bennett Corporation, 1990).
648 • CHAPTER TWENTY-EIGHT

Flows
(L/min) ASL 5000 Run Time Display IngMar Medical Adult/Pediatric Lung Model: Settings C=1, R=3, no leaks
150 600

120 500
100
400

Volume (ml)
80
60 300
40
20 200
0 100
–20 (A)
–40 0
–60 0 2 4 6
(B)
–80
Figure 28-16 Air trapping, shown by the failure of the volume
–100
wave form to reach zero before the next breath is delivered
–120
14.7 Time 22.7

Figure 28-14 Differences in airway resistance. At (A), the slope is

less and expiratory time is greater. The portion of the curve labeled (A)
30
(B) illustrates decreased resistance with a greater slope and shorter
expiratory time.
(B)

Paw
Volume versus Time cm H2O
The volume versus time wave form is illustrated in Figure SEC
28-15. Analysis of this graphical display allows the deter- 1 2 3 4 5 6
-10
mination of tidal volume, detection of air trapping, and (A)
identification of breath type. Tidal volume is the peak
12
value reached during inspiration. By reading the value on
(B)
the vertical axis in liters, tidal volume delivery may be
determined. VT
Air trapping is evident from failure of the volume wave LITERS
form to reach zero during exhalation (Figure 28-16). SEC
1 2 3 4 5 6
Insufficient expiratory time has been allowed, and gas is -4

trapped in the lungs. Decreasing the ventilatory rate or Figure 28-17 Mandatory breaths (A) have large volumes when
increasing inspiratory flow may allow for sufficient exha- compared with spontaneous breaths (B).
lation time, returning the expiratory volume to zero prior
to delivery of the next breath.
Spontaneous and mandatory breath delivery may be 1996). The two most common combined wave forms are
assessed by observing the volume versus time wave form. pressure versus volume and flow versus volume loops.
Mandatory breaths have larger volumes than do sponta- The graphical display presents information for each scalar
neous breaths (Figure 28-17). relative to each other and to time.
Pressure versus Volume
Combined Wave Forms The pressure versus volume loop is shown in Figure 28-18.
Combined wave forms are combination displays of two Volume is on the vertical axis, while pressure is on the hor-
scalar wave forms that form a loop (Nilsestuen & Hargett, izontal axis. Positive pressure is displayed to the right of
the volume scale, while subambient pressure is displayed
IngMar Medical Adult/Pediatric Lung Model: Settings C=n/s, R=1, no leaks
to the left of it. Inspiration progresses from the zero point
to the right, while exhalation moves from right to left. This
1000
graphical display is helpful in determining tidal volume
800 and inspiratory work and in detecting overdistention and
changes in compliance and resistance.
Volume (ml)

600 Tidal volume delivery during both spontaneous and

mandatory breaths is reflected by the maximum value
400
attained on the vertical (volume) axis. Tidal breath deliv-
200 ery may be measured directly using this technique.
With spontaneous breath, the graphical loop progresses
0 clockwise from the zero point (moving into subambient
0 2 4 6
pressures) until the tidal volume is reached; with exhala-
Figure 28-15 A volume versus time graphical display. Volume is tion it continues clockwise, displaying positive pressures
on the vertical axis, while time is on the horizontal axis. (Figure 28-19).
 WAVE FORM ANALYSIS • 649

IngMar Medical Adult/Pediatric Lung Model: Settings C=n/s, R=1, no leaks IngMar Medical Adult/Pediatric Lung Model: Settings C=n/s, R=1, no leaks

800

600
600
Volume (ml)

Volume (ml)
400
400

200

200
Pressure (cm H2O)
0
0 5 10 15 20

(A)
Figure 28-18 A pressure versus volume graphical display. Volume
is displayed on the vertical axis, while pressure is displayed on the
horizontal axis.
(B) Pressure (cm H2O)
0
0 10 20 30 40 50

VT Figure 28-20 Two different mandatory breaths with differing inspi-

LITERS ratory work levels. Loop (A) shows the same volume delivery at a
BASELINE = 0 cm H2O 1.2 reduced level of work; loop (B) represents greater work (larger area in
RELATIVE PRESSURE RANGE = 60 cm H2O the subambient range).
INSPIRATORY AREA = 0.116

0.8
A B Volume
(ml) ASL 5000 Run Time Display
800
0.4
750
700
Paw 650
cm H2O
-60 -40 -20 0 20 40 60 600
550
Figure 28-19 A spontaneous pressure versus volume loop. Note 500
how inspiration is in the subambient pressure range, while expiration 450
is positive. The loop progresses clockwise from left to right. 400
350
300
Inspiratory work is reflected by the portion of the loop 250
that remains in the subambient pressure range. Inspiratory 200
work is generated by the primary muscles of ventilation. 150
By making ventilator adjustments to minimize the area of
100
the loop in the subambient pressure range, work may be
50
minimized. Adjustments may include sensitivity (pressure
0
or flow triggering), inspiratory flow, and baseline flow set- 0 5 10 15 20 25 30 35
tings. Figure 28-20 illustrates two mandatory breaths Pressure (cm H2O)
delivered at different inspiratory work levels.
Overdistention occurs when pressure continues to rise Figure 28-21 An example of overdistention. Note how pressure
rises without continued volume delivery.
without concomitant volume delivery (Figure 28-21). This
phenomenon results in a graph feature referred to as
“beaking” because the curve looks similar to a bird’s beak. subjected to higher pressures with little or no change in vol-
Overdistention causes the lungs to be stretched, being ume. To minimize this effect, pressure or volume should be
650 • CHAPTER TWENTY-EIGHT

IngMar Medical Adult/Pediatric Lung Model: C=n/s, R=1; and C=1+2, R=1 IngMar Medical Adult/Pediatric Lung Model: C=n/s, R=3; and C=n/s, R=1

800 800
(A)
(A) (B)
(B)
600 600
Volume (ml)

Volume (ml)
400 400

200 200

Pressure (cm H2O) Pressure (cm H2O)

0 0
0 20 40 60 80 0 20 40 60 80

Figure 28-22 Two pressure-volume loops with differing Figure 28-23 Two pressure-volume loops with different airway
compliance. Loop (A) represents a higher compliance (more volume resistances. Loop (A) shows the same volume and compliance at a
change for a given pressure), while loop (B) represents a lower lower resistance; loop (B) displays a greater hysteresis (space between
compliance. inspiratory and expiratory traces) and resistance.

lowered (depending on which is a control variable) to IngMar Medical Adult/Pediatric Lung Model: Settings C=n/s, R=1; C=n/s, R=3
match more closely the compliance of the lung/thoracic 80
system.
Changes in compliance may be assessed by observing (B)
the slope of the pressure versus volume loop (Figure 60
28-22). An increased compliance is represented by
a steeper slope. More volume is attained at a lower
pressure, whereas decreased compliance is represented 40 (A)
by a lower slope (smaller volume change for a given
pressure).
Changes in airway resistance may be assessed by ob- 20
serving the hysteresis displayed in the loop. Hysteresis is
Flow (L/min)

the space between the inspiratory and expiratory loops. Volume (ml)
Two loops of differing airway resistances are shown in 0
Figure 28-23. The loop with greater resistance—loop 200 400 600 800 1000
(B)—is referred to as “bowed”—that is, the inspiratory (A)
portion is more rounded and distends toward the pres- –20
sure axis.

Flow versus Volume –40

Flow-volume loops are commonly used in the evaluation (B)
of spirometry readings (Fitzgerald, Speir, & Callahan,
1996). This graphical display plots flow on the vertical axis –60
and volume on the horizontal axis (Figure 28-24). Flow-
volume loops are helpful in assessing changes in airway
resistance, which may often be detected after bronchodila-
–80
tor administration. When airway resistance is improved,
expiratory flows are greater and the slope of the tracing is Figure 28-24 A flow-volume loop display. Part (A) indicates
also steeper (Nilsestuen & Hargett, 1996). greater RAW, while (B) reflects decrease RAW.
 WAVE FORM ANALYSIS • 651

PROFICIENCY
OBJECTIVES
At the end of this chapter, you should be able to: • Demonstrate how to interpret a selected wave
• Demonstrate how to select the desired wave form form.
for display: • Demonstrate how to select an appropriate wave
— Pressure-time form to assess:
— Flow-time — Patient effort
— Volume-time — Air trapping or auto PEEP
— Pressure-volume — Inspiratory flow
— Flow-volume — Airway resistance

Wave form selection will vary depending upon the venti- a breath represents ventilatory work. Both displays show
lator being used. Graphics may be selected by depressing subambient pressure changes during inspiration. Some
soft or hard keys on the display, and function keys on the ventilators use the pressure-volume graphical display and
control panel or by scrolling through menu options. You actually measure the area representing the subambient
should learn how to utilize the graphical display monitors portion of the breath. By comparing changes in this area
for each of the ventilators used in your institution with different ventilator settings, adjustments can be made
(whether a college or a clinical facility). Graphical analysis to minimize patient work or effort.
is important in patient assessment, and your ability to use Air trapping, or auto PEEP, may be assessed using
these systems quickly and comfortably will enable you to either the flow-time or volume-time graphical display. For
deliver good patient care. either display, determine whether exhalation (flow or vol-
ume) reaches zero prior to delivery of the next breath. If air
trapping or auto PEEP is not desired, make ventilator
adjustments to minimize it. Your laboratory or clinical
WAVE FORM INTERPRETATION
instructor can assist you in learning to recognize this, and
Once the desired wave form is selected, you must be able when it is and is not appropriate for a given patient.
to interpret the wave form. Common clinical variables and Adequacy of inspiratory flow during mandatory
problems that graphical analysis helps to assess include (ventilator) breaths may be assessed using pressure-time,
volume delivery, inspiratory work, overdistention, and volume-time, and volume-pressure graphical displays.
compliance and resistance changes. Your laboratory and It is important to ensure that the flow setting is adequate
clinical instructors can assist you in learning how to inter- for the patient’s flow demands. It is not uncommon to
pret changes in the wave forms displayed on the ventilator observe the patient actively working during a mandatory
monitor. Using the theoretical concepts presented earlier breath (volume-pressure or flow-time). If you detect this,
in this chapter, practice interpreting wave forms every adjust the flow to meet the patient’s needs. Your clinical
time you are at the bedside caring for patients. Only instructor can assist you in learning how to interpret
through repeated practice can you become proficient at this event.
this new skill. Changes in compliance may be assessed using the
pressure-volume graphical display. By assessing the slope
of the loop, changes in compliance may be determined.
CLINICAL CRITERIA FOR Your laboratory and clinical instructors can assist you in
learning to interpret these changes. Sometimes they are
APPROPRIATE WAVE FORM
subtle and require interpretation by an experienced clini-
SELECTION cian. Experience and practice will help you in learning to
Depending on the clinical question, some wave forms are assess these changes.
better than others for obtaining the desired information. Changes in airway resistance may be assessed using
Clinical scenarios involving patient effort, air trapping, both the volume-pressure and flow-volume graphical dis-
adequacy of inspiratory flow, and changes in airway resist- plays. Changes in hysteresis (volume-pressure) and peak
ance and compliance are commonly assessed using venti- flow (flow-volume) are indicative of changes in airway
lator graphics. resistance. Make it a habit to assess these graphical dis-
Patient effort may be determined by observing the plays before and after bronchodilator administration. With
pressure-time and pressure-volume graphical displays. your clinical instructor, interpret these wave forms and
Subambient pressure generated by the patient in initiating learn to assess these subtle changes.
652 • CHAPTER TWENTY-EIGHT

References

Bear Medical Systems, Inc. (1987). BEAR 5 ventilator instruction manual. Riverside, CA: Author.
Chatburn, R. L. (1991) A new system for understanding mechanical ventilators. Respiratory Care, 36(10), 1123–1155.
Fitzgerald, D. J., Speir, W. A., & Callahan, L. A. (1996). Office evaluation of pulmonary function: Beyond the numbers.
American Family Physician, 54(2), 525–534.
Nilsestuen, J. O., & Hargett, K. (1996). Managing the patient-ventilator system using graphic analysis: An overview and
introduction to Graphics Corner. Respiratory Care, 41(12), 1105–1122.
Puritan-Bennett Corporation. (1990). Waveforms: The graphical presentation of ventilatory data, Form AA-1594.
Carlsbad, CA: Author.
White, G. (1999). Equipment theory for respiratory care (3rd ed.). Clifton Park, NY: Delmar Learning.

Practice Activities: Wave Form Analysis

1. Using a test lung, set up the ventilator(s) used at your the changes in the following wave form graphical
institution and practice selecting the following wave displays:
forms: a. Flow-time
a. Pressure-time b. Volume-time
b. Flow-time c. Pressure-volume
c. Volume-time d. Flow-volume
d. Pressure-volume 3. Using a lung analog (Retec or Manley), establish routine
e. Flow-volume continuous mechanical ventilation settings. Have your
2. Using a lung analog (Retec or Manley) in which com- laboratory partner change compliance, resistance, or both
pliance and resistance may be altered, change the without your being able to see the lung analog. Assess
compliance, the resistance, and then both, and observe the ventilator graphics and state what has been changed.

Check List: Wave Form Analysis

1. Verify the physician’s order. 5. Interpret the wave form for:

2. Scan the patient’s chart as time permits. a. Inspiratory flow
3. Wash hands before seeing the patient. b. Inspiratory work
4. Select the desired wave form: c. Overdistention
a. Pressure-time d. Changes in compliance
b. Flow-time e. Changes in resistance
c. Volume-time 6. Adjust ventilator as required.
d. Pressure-volume 7. Chart appropriately on the patient record.
e. Flow-volume 8. Wash hands upon leaving the area.

Self-Evaluation Post Test: Wave Form Analysis

1. Which of the following wave form displays are 3. Which of the following wave forms may be used to
scalars? assess inspiratory work?
I. Pressure-time a. I, III I. Pressure-time a. I, II
II. Pressure-volume b. I, IV II. Pressure-volume b. I, III
III. Flow-time c. II, III III. Flow-time c. II, III
IV. Flow-volume d. II, IV IV. Flow-volume d. III, IV
4. In assessing the pressure-volume wave form, which
2. Which of the following wave forms may be used to of the following would indicate a change in airway
assess adequacy of inspiratory flow? resistance?
I. Pressure-time a. I a. Increased hysteresis
II. Flow-time b. I, II b. Increased slope
III. Pressure-volume c. I, II, III c. Decreased slope
IV. Flow-volume d. I, II, III, IV d. Increased volume
 WAVE FORM ANALYSIS • 653

5. In assessing the pressure-volume wave form for 8. Which of the following is indicated when volume
changes in compliance, which of the following reflects fails to reach zero during exhalation in assessing the
an increase in lung/thoracic compliance? volume-time graphical display?
a. Increased hysteresis a. Increased compliance
b. Increased slope b. Decreased compliance
c. Decreased slope c. Increased resistance
d. Increased volume d. Air trapping
6. In assessing the pressure-volume wave form for 9. “Bowing” of the pressure-volume curve toward the
changes in compliance, which of the following reflects pressure axis is indicative of:
a decrease in lung/thoracic compliance? a. increased compliance.
a. Increased hysteresis b. decreased compliance.
b. Increased slope c. increased resistance.
c. Decreased slope d. air trapping.
d. Increased volume 10. A positive response to bronchodilator therapy is indi-
7. In assessing the flow-time wave form, air trapping is cated by which of the following changes in the flow-
manifested by: volume graphical display?
a. an increased slope. I. Increased slope a. I, II
b. lower flow rates. II. Increased peak flow b. I, III
c. shorter inspiratory times. III. Decreased slope c. II, III
d. flow not reaching zero. IV. Decreased peak flow d. III, IV
 PERFORMANCE EVALUATION:
WAVE FORM ANALYSIS

Date: Lab ________________________ Clinical ________________________ Agency _________________________

Lab: Pass ______ Fail ______ Clinical: Pass ______ Fail ______
Student name ______________________________________ Instructor name _____________________________________
No. of times observed in clinical ______
No. of times practiced in clinical ______

PASSING CRITERIA: Obtain 90% or better on the procedure. Tasks indicated by * must receive at least 1 point, or
the evaluation is terminated. Procedure must be performed within designated time, or the
performance receives a failing grade.

SCORING: 2 points — Task performed satisfactorily without prompting.

1 point — Task performed satisfactorily with self-initiated correction.
0 points — Task performed incorrectly or with prompting required.
NA — Task not applicable to the patient care situation.

TASKS: PEER LAB CLINICAL

* 1. Verifies the physician’s order n n n
* 2. Reviews the patient’s chart n n n
* 3. Washes hands n n n
4. Selects the desired wave form
* a. Pressure-time n n n
* b. Flow-time n n n
* c. Volume-time n n n
* d. Pressure-volume n n n
* e. Flow-volume n n n
5. Interprets the wave form for
* a. Inspiratory flow n n n
* b. Inspiratory work n n n
* c. Overdistention n n n
* d. Changes in compliance n n n
* e. Changes in resistance n n n
* 6. Adjusts ventilator as required n n n
* 7. Charts appropriately on the patient record n n n
* 8. Washes hands upon leaving the area n n n

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SCORE: Peer _________ points of possible 26; _________%
Lab _________ points of possible 26; _________%
Clinical _________ points of possible 26; _________%
TIME: _________ out of possible 15 minutes

STUDENT SIGNATURES INSTRUCTOR SIGNATURES

PEER: _________________________________________ LAB: _________________________________________
STUDENT: _________________________________________ CLINICAL: _________________________________________

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