Identify Patient-Ventilator Asynchrony

Using Ventilator Graphics to Identify Patient-Ventilator Asynchrony
Jon O Nilsestuen PhD RRT FAARC and Kenneth D Hargett RRT
Introduction
Trigger Asynchrony (Phase 1)
Trigger Asynchrony Can Occur in Any Ventilation Mode
Flow Asynchrony (Phase 2)
Volume Ventilation With a Fixed Flow Pattern
Pressure Ventilation With Variable Flow
Termination Asynchrony (Phase 3)
Delayed Termination
Premature Termination
Expiratory Asynchrony (Phase 4)
Summary
Patient-ventilator interaction can be described as the relationship between 2 respiratory pumps: (1) the
patient’s pulmonary system, which is controlled by the neuromuscular system and influenced by the
mechanical characteristics of the lungs and thorax, and (2) the ventilator, which is controlled by the
ventilator settings and the function of the flow valve. When the 2 pumps function in synchrony, every
phase of the breath is perfectly matched. Anything that upsets the harmony between the 2 pumps results
in asynchrony and causes patient discomfort and unnecessarily increases work of breathing. This article
discusses asynchrony relative to the 4 phases of a breath and illustrates how asynchrony can be iden-
tified with the 3 standard ventilator waveforms: pressure, flow, and volume. The 4 phases of a breath
are: (1) The trigger mechanism (ie, initiation of the inspiration), which is influenced by the trigger-
sensitivity setting, patient effort, and valve responsiveness. (2) The inspiratory-flow phase. During both
volume-controlled and pressure-controlled ventilation the patient’s flow demand should be carefully
evaluated, using the pressure and flow waveforms. (3) Breath termination (ie, the end of the inspiration).
Ideally, the ventilator terminates inspiratory flow in synchrony with the patient’s neural timing, but
frequently the ventilator terminates inspiration either early or late, relative to the patient’s neural
timing. During volume-controlled ventilation we can adjust variables that affect inspiratory time (eg,
peak flow, tidal volume). During pressure-controlled or pressure-support ventilation we can adjust
variables that affect when the inspiration terminates (eg, inspiratory time, expiratory sensitivity). (4)
Expiratory phase. Patients with obstructive lung disease are particularly prone to developing intrinsic
positive end-expiratory pressure (auto-PEEP) and therefore have difficulty triggering the ventilator.
Bedside evaluation for the presence of auto-PEEP should be routinely performed and corrective ad-
justments made when appropriate. Key words: ventilator graphics, waveforms, asynchrony, patient-venti-
lator interface. [Respir Care 2005;50(2):202–232. © 2005 Daedalus Enterprises]
Introduction cade. Both direct and anecdotal evidence (see below), how-
ever, suggests that bedside use of ventilators’ graphics
Ventilator graphics are available on almost all current capabilities is widely underutilized, and standard ap-
mechanical ventilators and have been available for evalu- proaches or guidelines for graphics interpretation are often
ating the patient-ventilator interface for more than a de- lacking.
202 RESPIRATORY CARE • FEBRUARY 2005 VOL 50 NO 2

USING VENTILATOR GRAPHICS TO IDENTIFY PATIENT-VENTILATOR ASYNCHRONY
Table 1. Factors That Affect Patient-Ventilator Synchrony
Ventilator Factors
Trigger variables: esophageal pressure, flow, or shape signal
Sensitivity setting
Rise-time capability
Design, mode, and settings of the flow delivery system
Flow pattern selected
Design of the exhalation valve
How positive end-expiratory pressure is generated by the software
Extraneous flow (eg, from a nebulizer or added oxygen)
Patient Factors
Sedation level: pain, splinting
Inspiratory effort/respiratory drive; neural timing
Pathology of the respiratory system or abdomen; secretions
Intrinsic positive end-expiratory pressure
Fig. 1. The primary causes of ventilator-related deaths, 1995–2003. Size and type of airway
(Adapted from Reference 1, with permission.) Presence of leaks
In a recent Joint Commission on Accreditation of Health

Table 2. Deleterious Effects of Patient-Ventilator Asynchrony
Care Organizations report on ventilator safety,1 human
error was identified as an important factor. Further inves- Patient fights the ventilator
tigation of the reported errors identified “orientation and More sedation required
training” as the most frequent root cause of problems (Fig. Higher work of breathing
1). In addition, only about one third of the members of the Muscle damage
respiratory care profession who are responsible for the Ventilation-perfusion problems
bedside monitoring of patients receiving mechanical ven- Dynamic hyperinflation
tilation subscribe to the RESPIRATORY CARE Journal, which Delayed or prolonged weaning
indirectly suggests that some information regarding graph- Longer stay
ics monitoring is probably not widely distributed. One of Higher costs
the reasons for the current Journal Conference was to gather
graphical information, because it is not widely published
or synthesized in the recent literature. Also, during our gests wide differences in the general understanding of wave-
presentations on ventilator waveforms at the International form interpretation.
Respiratory Congresses in recent years, we used an audi- In describing the interaction between the patient and the
ence-participation feedback system to test the audience ventilator, Kondili et al2 offered an insightful definition of
with waveform-analysis questions (unpublished data). The patient-ventilator synchrony/asynchrony: “During mechan-
correct response rate ranged from 25% to 75% for fairly ical ventilation the respiratory system is affected by 2
simple graphics analysis questions, which we believe sug- pumps: the ventilator controlled by the physician [or cli-
nician] and the patient’s own respiratory muscle pump.
Patient-ventilator interaction is an expression of these 2
controllers, which should be in harmony if the result is to
Jon O Nilsestuen PhD RRT FAARC is affiliated with the Department of be appropriate for the patient.”
Respiratory Care, University of Texas Medical Branch, School of Allied
Though the number of additional factors affecting each
Health Sciences, Galveston, Texas. Kenneth D Hargett RRT is affiliated
with the Department of Respiratory Care, The Methodist Hospital, Texas of the 2 controllers is fairly substantial (Table 1), the basic
Medical Center, Houston, Texas. description of the 2 pumps being in harmony provides a
clear goal for what patient-ventilator synchrony should be;
Jon O Nilsestuen PhD RRT FAARC presented a version of this article at therefore, anything that falls short of that results in some
the 34th RESPIRATORY CARE Journal Conference, Applied Respiratory
Physiology: Use of Ventilator Waveforms and Mechanics in the Man- degree of asynchrony, which deserves analysis and cor-
agement of Critically Ill Patients, held April 16–19, 2004, in Cancún, rection. Failure to make appropriate adjustments to im-
Mexico. prove synchrony can cause various complications and del-
eterious consequences for the patient (Table 2).
Correspondence: Jon O Nilsestuen PhD RRT FAARC, Department of
Respiratory Care, University of Texas Medical Branch, School of Allied The present article reviews graphics methods for recog-
Health Sciences, 301 University Boulevard, Galveston TX 77555-1028. nizing patient-ventilator asynchrony and describes how graph-
E-mail: [email protected]. ics can be used to improve patient-ventilator interaction.
RESPIRATORY CARE • FEBRUARY 2005 VOL 50 NO 2 203

Fig. 2. Airway pressure (top), flow (middle), and volume (bottom) waveforms from a normal subject during synchronized intermittent
mandatory ventilation with pressure support. The 4 phases of the breath are numbered. Phase 1 is the initiation of patient effort, which
indicates achievement of the trigger threshold (2 cm H2O) that opens the inspiratory valve. Phase 2 represents the relationship between flow
delivery, as determined by the ventilator’s flow algorithm, and the patient effort (the first and third breaths are pressure support breaths,
in which flow is partially dependent on patient effort, and the second breath is the mandatory breath, which has a constant-flow pattern).
Notice the scooped-out appearance of the pressure waveform during the mandatory breath, which indicates that the inspiratory flow was
inadequate. Phase 3 is the breath-termination point, which varies based on the type of breath; for the middle breath the inspiratory time
is set on the ventilator, but the inspiratory time for the pressure support breath is based on the termination criterion, which in this case is
5% of the peak flow. Phase 4 is the expiration portion of the breath. During this phase the breath should be inspected for evidence of
intrinsic positive end-expiratory pressure (auto-PEEP). This expiratory flow waveform returns to zero prior to the next breath, which
indicates the absence of auto-PEEP.
The use of guidelines, standards, and protocols for as- “Although triggering composes only a small part of the entire
sessing and treating disease states improves patient out- inspiratory cycle, inappropriate setting or design may increase
comes.3 Similarly, a standard approach to analysis of ven- the patient’s effort and inspiratory muscle work.”4,5
tilator waveforms should improve patient comfort, reduce “In a demand-flow system (pressure-trigger), the trig-
work of breathing (WOB), and perhaps improve outcomes. ger variable is a set pressure that must be attained at the
Evaluation of patient-ventilator synchrony can be broken onset of inspiration for the ventilator to deliver fresh
down into 4 phases (Fig. 2): evaluation of triggering; eval- gas into the inspiratory circuit.”4 Most microprocessor-
uation of adequate flow delivery; evaluation of breath ter- based ventilators use pressure-triggering to initiate both
mination; and evaluation of intrinsic positive end-expira- the mandatory breaths (assist-control and synchronized
tory pressure (auto-PEEP), which is the primary clinical intermittent mandatory ventilation) and spontaneous
complication associated with the expiratory phase. For or- breaths (continuous positive airway pressure, synchro-
ganization purposes and as a methodical approach for cli- nized intermittent mandatory ventilation, pressure sup-
nicians to use at the bedside, the present article is orga- port ventilation).4
nized according to these 4 phases.
Definition: Trigger Asynchrony. This term has been
Trigger Asynchrony (Phase 1) defined as “muscular effort without ventilator trigger.”6
Though this definition describes the problem when patient
Definition: Trigger. “The trigger variable is defined as effort fails to trigger the ventilator, we will also discuss
the variable that is manipulated to deliver inspiratory flow.”4 several additional triggering problems: double-triggering,

Fig. 3. Schematic of a typical breath. P-T ⫽ trigger pressure. D-T ⫽ inspiratory trigger time. D-B ⫽ time to return airway pressure to zero.
D-I ⫽ inspiratory delay time. Area 1 ⫽ trigger pressure-time product. D-E ⫽ expiratory time delay. P-E ⫽ supra-plateau expiratory pressure
change. Area E ⫽ expiratory pressure area. (From Reference 7, with permission.)
auto-triggering, and insensitive trigger (triggering that re- the breath until after the inspiratory delay time has passed.
quires excessive patient effort). If we account for the pressure-drop across the endotra-
Trigger asynchrony is only one type of problem asso- cheal tube and the potential presence of auto-PEEP, the
ciated with a patient fighting the ventilator. Though bed- patient may not receive any positive inflation support until
side clinicians are inclined to think of trigger problems as some time after the inspiratory delay time has passed.
being associated primarily with the sensitivity setting on Currently, there are only 2 common types of trigger mech-
the ventilator, the definition has been expanded to address anism available on commercial ventilators in the United States:
other variables that are influenced by the patient’s inspira- pressure trigger and flow trigger. Though initial clinical stud-
tory effort or respiratory drive, and the rate at which the ies indicated that flow-triggering offered some advantage in
ventilator supplies gas to the circuit (Fig. 3).7 These vari- reducing trigger asynchrony, recent advances in the develop-
ables include (1) the traditional “trigger pressure” or “valve ment of pressure transducers have resulted in nearly equiva-
sensitivity,” which can be adjusted by the clinician; (2) the lent or comparable results.8 –10 A third type of trigger mech-
pressure maximum, which is the most negative pressure or anism—the shape-signal or “shadow” trigger—is available in
largest downward deflection in the airway pressure wave- the European market and is now available in the United States
form—this value may be more negative than the trigger as “AutoTrak” on the Respironics BiPAP ventilator.11 This
pressure if the patient has a strong respiratory drive; (3) shape-signal mechanism uses a mathematical model derived
the inspiratory trigger time, which is the time elapsed be- from the pressure and flow signals;12,13 it has some promise
tween the initial patient effort and the point at which the for reducing trigger asynchrony, and it may be better toler-
airway pressure reaches the maximum baseline pressure— ated.14 –19 Initial clinical studies have looked at various ap-
for patients with low respiratory drive, it takes longer for plications of this derived signal, such as inclusion in propor-
the airway pressure to reach the trigger pressure; (4) time tional-assist algorithms, but this triggering mechanism still
to return trigger pressure to zero or baseline—this time is has some problems with repetitive auto-cycling (runaway).15,20
affected by how rapidly the ventilator is able to supply
flow to pressurize the circuit, and is influenced by the
Trigger Asynchrony Can Occur in Any Ventilation
slope setting; and (5) the inspiratory delay time, which is
Mode
the total time delay from the initial patient effort until the
pressure waveform returns to baseline—this is the sum of
the inspiratory trigger time and the time to return trigger to Clinical studies indicate that ventilator-dependent pa-
baseline. The patient does not receive any assistance with tients experience trigger asynchrony in all of the common

Fig. 4. Flow and pressure waveforms from a patient during assist-

control ventilation (ACV), pressure support (PS) of 100%, intermit-
tent mandatory ventilation (IMV) of 80%, and unassisted breathing
through the ventilator circuit (CPAP 0). The arrows indicate in-
spiratory attempts that failed to trigger the ventilator. These failed
efforts can also be seen in the expiratory flow waveforms, as
abrupt decreases in expiratory flow. In the ASV waveform, note
the progressive increase in peak airway pressure in breaths that
precede nontriggering efforts, which suggests dynamic hyperin-
flation. (From Reference 21, with permission.) Fig. 5. Total trigger attempts (inspiratory efforts) and failed trigger
attempts during pressure support (PS) ventilation, intermittent man-
datory ventilation (IMV), and IMV with pressure support of 10 cm
ventilation modes, including assist-control ventilation (con- H2O. The black portion of each bar represents the failed trigger
tinuous mandatory ventilation), pressure support ventila- attempts, and the overall bar height represents the total number of
inspiratory attempts during 1-min. With increasing pressure sup-
tion, intermittent mandatory ventilation, and continuous
port the total number of inspiratory attempts progressively de-
positive airway pressure (Fig. 4).21 Investigation into the creased, but the number of nontriggering attempts increased. With
cause or pattern associated with trigger asynchrony reveals increasing levels of intermittent mandatory ventilation the total num-
2 major points. The first point has to do with the effect that ber of inspiratory attempts progressively decreased, but the num-
mechanical ventilation has on the patient’s drive to breathe. ber of nontriggering attempts increased. With increasing levels of
intermittent mandatory ventilation plus pressure support of 10 cm
As additional support is provided by the base mode of the
H2O the total number of inspiratory attempts progressively de-
ventilator, the patient’s drive to breathe decreases, so pa- creased, but the number of nontriggering attempts increased. (From
tient effort subsides and the tendency for trigger asyn- Reference 21, with permission.)
chrony or failed trigger attempts increases (Fig. 5). Addi-
tional clinical evidence from esophageal pressure
recordings to measure respiratory muscle activity further in pressure support cause a decrease in respiratory drive
supports the reduction in patient effort associated with (dP/dt), associated with considerable increase in the trig-
increasing ventilatory support (Fig. 6). Leung et al found gering time” (Fig. 7). If Pmus [respiratory muscle effort
that: “Progressive increases in intermittent mandatory ven- measured with an esophageal balloon] pressure increases
tilation alone and pressure support alone reduced inspira- slowly, for example when respiratory drive is small (low
tory effort and dyspnea.”21 PaCO2, sedation, sleep, high level of assist), the time be-
Leung et al21 also evaluated the impact of pressure sup- tween onset of inspiratory effort and ventilator-triggering
port on respiratory drive and found that “graded increases increases, causing asynchrony. If inspiratory effort is great

Fig. 7. Graded increases in pressure support cause a decrease in

respiratory drive (dP/dt), which is associated with considerable
increase in the triggering time. (From Reference 2, with permis-
sion.)
(high metabolic rate, high PaCO2, reduced sedation, reduced

ventilatory assistance), then both the rate of increase in
Pmus and peak Pmus will increase, allowing synchrony.2,21
Fig. 6. Pressure-time product (PTP) of the trigger phase (PTPtrigger) During intermittent mandatory ventilation with pressure
(black portions of the bars), post-trigger phase (white portions of support, a comparison of the patient effort exerted during
the bars), and total PTP/breath (the sums of the black and white the mandatory, ventilator-delivered breath (mandatory
portions of the bars) during graded levels of pressure support (PS).
As the level of ventilator assistance was decreased, PTP/breath
breath) and during the intervening pressure support breath
and the PTP of the post-trigger phase increased, whereas PTPtrigger indicates a unique (but perhaps not surprising) relation-
remained the same. The middle panel shows the PTPtrigger (black ship: the effort during the intervening breaths is carried
portions of the bars), the PTP of the post-trigger phase of the over to the mandatory breaths (Fig. 8).21 This raises a
mandatory breaths (hatched bars), and the PTP of the intervening fundamental problem with the intermittent nature of inter-
unassisted breaths (white portions of the bars) during intermittent
mandatory ventilation (IMV) without pressure support. Total
mittent mandatory ventilation. Patients have difficulty al-
PTP/breath is represented by the sums of the black and white (or tering their respiratory drive between supported and un-
hatched) portions of the bars. As the level of ventilator assistance supported breaths. Their respiratory effort seems to be
was decreased, PTP/breath and PTP of the post-trigger phase of equivalent for both the ventilator-assisted breath and the
both the mandatory and intervening breaths increased, whereas intervening unassisted breaths.
PTPtrigger remained the same. For a given level of intermittent man-
datory ventilation (without pressure support), PTP/breath was sim-
ilar for the mandatory and intervening breaths. The lower panel
shows PTPtrigger (black portions of the bars), PTP of the post- ventilator assistance was decreased, PTP/breath and PTP of the
trigger phase of the mandatory breaths (hatched portions of the post-trigger phase of both the mandatory and intervening breaths
bars), and the intervening breaths (white portions of the bars) dur- increased, whereas PTPtrigger remained the same. For a given level
ing intermittent mandatory ventilation with pressure support of of intermittent mandatory ventilation with pressure support, PTP/
10 cm H2O. Total PTP/breath is represented by the sums of the breath was similar for the mandatory and intervening breaths. (From
black and white (or hatched) portions of the bars. As the level of Reference 21, with permission.)

The preceding breaths had a shorter total-breathing-cy-

cle time, shorter expiratory time, longer inspiratory time,
and a longer ratio of inspiratory time to total-breathing-
cycle time than did the breaths that successfully triggered
the ventilator. The consequence is a higher level of auto-
PEEP at the onset of breaths that were missed than with
those that successfully triggered.
This creates an interesting scenario, because the timing
mechanisms during the breath substantially impact the cre-
ation and development of auto-PEEP, and it is the pres-
ence of auto-PEEP that in many instances prevents the
patient’s effort from being transmitted to the sensor mech-
anism to trigger the ventilator. Thus, auto-PEEP is a dy-
namic condition—in some instances occurring on a breath-
by-breath basis—and is probably one of the major causes
of trigger asynchrony with patients in whom we would not
normally suspect air-trapping as a result of their disease
state. The presence of auto-PEEP creates a larger pressure
gradient (between intrinsic lung pressure and ventilator
Fig. 8. The change in pressure-time product per breath (PTP/br)
during mandatory breaths with the addition of pressure support of
circuit pressure) that the patient must overcome to reach
10 cm H2O to a given level of intermittent mandatory ventilation the trigger threshold. The addition of ventilator-applied
was correlated with the change in respiratory drive (dP/dt) effected PEEP reduces that pressure gradient and moves the circuit
by pressure support during the intervening breaths (r ⫽ 0.67, pressure closer to the intrinsic airway pressure, in effect
p ⬍ 0.001). Unloading by a given level of intermittent mandatory reducing the pressure-drop the patient must create to trig-
ventilation was increased in proportion to the ability of pressure
support to decrease respiratory drive in the intervening breaths.
ger the ventilator.
(From Reference 21, with permission.) Patients with chronic obstructive pulmonary disease
(COPD) have a high prevalence of trigger problems as a
A decline in the mandatory rate of intermittent man- result of auto-PEEP, which can be caused either by the
datory ventilation resulted in a decrease in average patient’s lung pathology or by manipulation of the venti-
tidal volume, with inevitable increase in dead space. lator.2,22–24 Many of these studies have confirmed the pres-
To avoid a decrease in alveolar ventilation, patients ence of trigger asynchrony with the esophageal pressure
must increase inspiratory effort or respiratory fre- waveform. Though use of the esophageal pressure-monitor
quency, both of which they did. The resulting in- seems to be nearly a clinical research standard for evalu-
crease in drive is carried over to the mandatory ation of trigger problems, it is interesting to note that in
breaths, since the respiratory center does not switch many instances the patient’s missed trigger efforts can be
off at the moment that ventilator assistance com-
identified in the flow waveform and often in the pressure
mences.21
waveform as well (Fig. 9). In the flow waveform these
efforts often appear as a sudden movement of the expira-
The latter observation that the respiratory center does tory flow waveform toward the zero baseline (convexity)
not immediately switch off is further supported by the and a concomitant drop in the airway pressure waveform
close association between the respiratory drive (as mea- toward baseline (concavity). The clinical identification of
sured by the rate of decrease of the esophageal pressure trigger efforts using the flow and pressure waveforms is of
waveform) and the post-trigger pressure-time product. That practical importance because commercial use of esopha-
means that the respiratory drive at the onset of the breath geal pressure-monitoring is currently of limited access; the
is a major determinant of the effort expended after trig- technology is now available from only one ventilator man-
gering has occurred.21 ufacturer (Viasys, Palm Springs California).
The second major point associated with trigger asyn- In a study involving patients receiving long-term me-
chrony has to do with the effect of breathing-cycle dy- chanical ventilation Chao et al6 identified missed efforts in
namics (the relationship between inspiratory time, expira- the esophageal-pressure waveform (see the arrows in the
tory time, and total-breathing-cycle time) on the creation upper portion of Fig. 10). Improvement in the trigger cap-
of auto-PEEP. While investigating the potential causes of ture rate was accomplished by adding ventilator-applied
missed trigger attempts, Leung et al21 evaluated the cycle PEEP, as seen in the lower portion of Figure 10. As noted
timing associated with the breaths preceding missed at- above, the addition of ventilator-applied PEEP moves the
tempts. ventilator trigger threshold closer to the patient’s intrinsic

Fig. 9. Flow, airway pressure (Paw), and esophageal pressure (Pes) in a patient with severe chronic obstructive pulmonary disease and
ventilated with pressure support. The dotted lines indicate the beginning of inspiratory efforts that triggered the ventilator. The thin, black
arrows indicate nontriggering inspiratory efforts. Notice the time delay between the beginning of inspiratory effort and ventilator triggering.
Ineffective (nontriggering) efforts occurred during both mechanical inspiration and expiration. Those ineffective efforts can easily be
identified on the flow waveform; ineffective efforts during mechanical inspiration abruptly increase inspiratory flow, whereas during expi-
ration they result in an abrupt decrease in expiratory flow (open arrows in the flow waveform). The set respiratory frequency is 12
breaths/min, but the patient is making 33 inspiratory efforts per minute. (From Reference 2, with permission.)
Fig. 10. The upper panel shows waveforms of esophageal pressure (Pes in cm H2O), pressure at the airway opening (Pao in cm H2O), and
flow (in L/min) from a tracheostomized patient with trigger asynchrony during flow-controlled, volume-cycled (assist/control) ventilation. The
patient’s inspiratory efforts are identified by the negative Pes swings. The positive end-expiratory pressure (PEEP) is set at zero. Pao
appropriately drops to zero during expiration, indicating little circuit or valve resistance. Trigger asynchrony is evident; there is one triggered
breath (white arrows) for every 3– 4 inspiratory efforts (black arrows point to nontriggering efforts). Prolonged expiratory flow is due to airflow
limitation. Pes swings have little effect on retarding the expiratory flow and even less effect on Pao, depending on the phase of expiration.
In the lower panel, PEEP was increased to 10 cm H2O, so Pao during expiration is 10 cm H2O. There is persistent flow at end-expiration,
which indicates auto-PEEP. Trigger asynchrony has improved; there is one triggered breath for every 2–3 inspiratory efforts. There is less
limitation of expiratory flow, and the Pes swings are more effective in retarding the persistent expiratory flow. Peak inspiratory pressure and
Pes have slightly increased (compared to the waveforms in the upper panel), which probably indicates a higher end-expiratory lung volume
and total PEEP level. (From Reference 6, with permission.)

Fig. 11. Flow-time waveform from a patient receiving intermittent

mandatory ventilation with pressure support. Large tidal volume
(VT) during the mandatory breath prolongs expiratory time (length-
ened time constant) that exceeds the patient’s neural timing mech-
anism. Additional patient efforts that fail to trigger the ventilator are
evident in the expiratory flow waveform. V̇ ⫽ flow. INH ⫽ inhala-
tion. EXH ⫽ exhalation. (Courtesy of Kenneth D Hargett RRT, The
Methodist Hospital, Texas Medical Center, Houston, Texas)
airway pressure, making it easier for the patient to achieve

the trigger pressure.
Figure 11 illustrates the impact of large tidal volumes
(VT) provided during the mandatory breaths and the im- Fig. 12. Waveforms of flow, airway pressure (Paw), and esophageal
pact on expiratory timing. Following the large mandatory pressure (Pes) from a patient recovering from acute lung injury and
breath, expiratory time is slightly prolonged and interferes ventilated with volume assist-control ventilation with constant in-
with the patient’s internal timing mechanism, so the next spiratory flow. In the second breath, tidal volume (not shown) was
decreased at the same inspiratory flow, which prematurely ended
inspiratory effort (seen as a sudden drop in the expiratory mechanical inspiration. Because inspiratory muscles continued to
flow, to nearly zero) occurs prior to completion of exha- contract (arrow), they developed pressure that overcame the elas-
lation. As in previous waveforms, this example illustrates tic recoil at the end of inspiration. As a result, Paw decreased
the importance of carefully evaluating the flow waveform below the triggering threshold and the ventilator therefore deliv-
to identify additional patient efforts. ered a new mandatory breath. The ventilator was triggered 3 times
by the 2 inspiratory efforts. Observe the high Paw of the third
Figures 12–14 illustrate a different type of trigger prob- mandatory breath, because lung volume was greater (the volume
lem: double-triggering. In complete contrast to the prob- of the third breath was added to that of the second). Notice also
lems associated with missed trigger attempts, double-trig- that the total breath duration of the patient’s second respiratory
gering results from patient demand or effort exceeding the effort was considerably longer than that of the first, owing to ac-
volume- or flow-delivery settings on the ventilator. In other tivation of the Hering-Breuer reflex by the high, volume-prolong-
ing, expiratory time. (From Reference 2, with permission.)
words, this is not generally a valve-sensitivity problem,
but a condition in which the flow or volume settings have
not been adjusted to meet the patient’s demand, or a con-
dition arises in which the patient has a sudden increase in is over. Inadequate flow or volume, however, requires
demand that far exceeds the normal settings implemented immediate intervention.
for the resting breathing condition. Valve sensitivity settings result in 2 additional types
In Figure 12, in the esophageal pressure waveform we of trigger problems: (1) auto-triggering and (2) insen-
can see the continued inspiratory effort exerted by the sitive valve, in which the sensitivity is set so that it is
patient despite the dramatic oscillations in the pressure too difficult for the patient to trigger. The first of these,
and flow waveforms. In Figures 13 and 14 the airway which is auto-triggering, is possible in all current trig-
pressure waveforms indicate inadequate flow (concave gering methods.2 “It may be caused by random noise in
or dished out pressure waveform) and the continuation the circuit, water in the circuit (which can cause abrupt
of patient effort, leading to double-triggering. Clinical changes in circuit resistance), leaks [circuit leaks; see
situations in which double-triggering might occur in- Fig. 15, cuff leaks, or chest tube leaks], and cardiogenic
clude sighs, breathing efforts associated with coughing, oscillations.”25,26 Setting the trigger-sensitivity requires
or more serious conditions in which the volume or flow balancing 2 objectives: to set the sensitivity as low as
settings are set inappropriately low. Sighs or coughing possible, so that it triggers with minimal patient effort,
may be considered normal if of short duration and with- yet set it high enough to avoid auto-triggering. Imanaka
out important adverse effects. They may be resolved by et al26 found that approximately 20% of cardiac surgery
temporarily disconnecting the patient until the episode patients experienced auto-triggering episodes during

Fig. 13. Double-triggering seen in flow and volume waveforms from volume-controlled ventilation. Continued subject effort during the
second breath causes the airway pressure to drop below the trigger threshold, which initiates an additional “stacked” breath. Note the large
increase in peak airway pressure caused by the stacked breath and the high peak expiratory flow following the stacked breath.
Fig. 14. Inadequate flow and volume result in double-triggering during volume-controlled ventilation. During the first breath, slow valve-opening
(#1, as seen early in the flow waveform) and inadequate peak flow cause the dished-out appearance of the pressure waveform (#2). In the second
breath, again the valve-opening is too slow (#2) and inadequate peak flow results in additional gas being pulled through the demand valve (#3),
as seen by the appearance of the flow bump near the end of the flow waveform and the additional tidal volume beyond the set volume (in the
volume waveform). Continued inspiratory effort by the subject results in a second trigger and a stacked breath (#4). The subject was breathing
through a mouthpiece and filter, and was disconnected following the stacked breath, as seen in the volume waveform.

Fig. 15. Auto-triggering created by small circuit leak (tubing connection). The waveform sequence is from a Bear 1000 ventilator, set on
intermittent mandatory ventilation plus 5 cm H2O of pressure support, connected to a Michigan Instruments test lung. The small leak caused
the circuit pressure to drop below the set positive end-expiratory pressure and trigger the ventilator.
flow-triggering (Fig. 16). Auto-triggering was more Flow Asynchrony (Phase 2)

prevalent in patients who had acquired valve disease
and had more dynamic circulatory characteristics (larger Flow asynchrony is the second of the 4 components to
heart size, larger cardiac output, higher ventricular fill- evaluate when analyzing patient-ventilator synchrony. Re-
ing pressure, and lower respiratory-system resistance). ferring back to the 2-pump model, flow asynchrony occurs
These characteristics result in larger cardiogenic pres- whenever the ventilator flow does not match the patient
sure oscillations, which when transmitted to the airway, flow. Flow asynchrony is a common problem, and the
can cause auto-triggering. flow setting may be the most frequently incorrectly-set
ventilator parameter.27 The following discussion of flow
Auto-triggering occurs more often with low respi- asynchrony is divided into 2 sections, based on the 2 gen-
ratory drive and breathing frequency and when dy-
eral methods for delivering gas: volume-controlled venti-
namic hyperinflation is absent. Such factors allow
lation with a fixed flow pattern, and pressure-controlled
zero flow for some time during expiration before
the next inspiration, making the system vulnerable ventilation with variable flow.
to triggering from changes of airway pressure that
are not caused by inspiratory effort.2 Volume Ventilation With a Fixed Flow Pattern
The adequacy of flow during volume-controlled venti-

In contrast to auto-triggering, an inappropriately set sen- lation can be evaluated with the pressure-time waveform
sitivity dial (insensitive valve) may result in triggering (Fig. 18).28 Since the total work performed during the
difficulty and unnecessary patient work (Fig. 17). Close breath is the sum of the patient work and the ventilator
inspection of the pressure and flow waveforms will indi- work, we can evaluate the relative contributions of both by
cate where patient effort begins and whether the valve is comparing the shapes of the pressure-time waveform dur-
appropriately responding to the patient’s effort. Another ing 2 different conditions: completely passive breathing,
common cause of missed trigger attempts is the addition of during which the waveform has a defined pattern based on
extra flow to the circuit during nebulizer treatments. To the type of flow (constant-flow, descending-ramp, or si-
avoid this, the trigger mechanism should be set to pres- nusoidal);29 and patient-triggered breathing, during which
sure-trigger (not flow-trigger), and the trigger sensitivity the additional patient effort “dishes out” (ie, makes con-
should be appropriately adjusted. The use of the newer cave) the pressure waveform, relative to the amount of
vibrating-mesh nebulizers eliminates this problem but may patient work performed. The hatched area in Figure 18
also increase costs. illustrates the pressure-time product and represents the ef-

Fig. 16. Representative flow, airway pressure (Paw), esophageal pressure (Pes), and arterial blood pressure (BP) waveforms from a patient
who underwent mitral-valve replacement and tricuspid annuloplasty for mitral stenosis, tricuspid regurgitation, and aortic regurgitation. With
triggering sensitivity set at 1 L/min (left), pressure support ventilation was activated between 2 synchronized intermittent mandatory
ventilation breaths. When trigger sensitivity was changed to 4 L/min (right), pressure support breaths disappeared and there was marked
oscillation in flow, Paw, and Pes. Cardiogenic oscillation was evaluated as the peak inspiratory-flow fluctuation (A), amplitude in the flow
oscillation (B), amplitude in airway pressure (C), and amplitude in esophageal pressure (D). Also note that the baseline of esophageal
pressure was elevated when auto-triggering occurred, suggesting hyperinflation of the lungs. (From Reference 26, with permission.)
fort the patient contributed to the delivery of the breath. form, we can determine that the ventilator has sensed the
Figure 19 illustrates the pressure pattern associated with a beginning of patient effort and correctly initiated the breath.
constant-flow mandatory breath during passive breathing. In this instance, however, as patient effort increases, the
Figures 20 and 21 illustrate breathing sequences during peak flow set on the ventilator no longer meets the pa-
which the first breath is passive and during the second tient’s flow demand and the airway pressure waveform
breath the patient took a more active role; note the dished becomes progressively dished out.
out appearance of the second breath. Figure 22 represents The reason for evaluating flow asynchrony is to adjust
a similar sequence, with increasing amounts of patient the ventilator to match the patient’s flow demand. This can
effort. generally be accomplished by adjusting the peak flow set-
Flow asynchrony is sometimes mistaken for trigger asyn- ting on the ventilator until the pressure waveform pattern
chrony, and in particular trigger problems associated with most closely represents the condition observed during pas-
incorrect sensitivity settings. The difference can be deter- sive breathing. However, the patient’s flow demand may
mined by carefully evaluating the vertical alignment of the vary considerably, based on the neural drive to breathe.
pressure and flow waveforms. Figure 23 illustrates a se- The flow variability is analogous to the difference in flow
quence in which patient effort progressively increased. By demand between the resting breathing pattern and that
adding vertical lines to the leading edge of the flow wave- associated with increasing athletic activity: the higher the

Fig. 17. Evaluating trigger sensitivity with the airway pressure and flow waveforms. The black arrows indicate initiation of mandatory
constant-flow breaths. The sensitivity setting is – 4 cm H2O. During the first inspiratory effort the trigger threshold is not reached and the
breath is time-triggered, but the patient effort is sufficient to pull gas through the demand valve (seen as the flow that precedes the
constant-flow pattern). The next patient effort occurs before the synchronized intermittent mandatory ventilation window is open and the
patient again pulls gas through the demand valve. The second mandatory breath is time-triggered (constant flow occurs during patient
exhalation). Preceding the third mandatory breath, patient effort reaches the trigger threshold, but again a small amount of gas is pulled
through the demand valve (the leading edge of the flow curve is slightly rounded).
exercise intensity, the greater the flow demand. As the

patient’s flow demand increases, the peak flow should be
adjusted accordingly. As with many physiologic variables,
there is no single value or flow setting that is appropriate
for all patients. Studies indicate that an initial peak-flow
setting of 80 L/min may be a reasonable place to start, but
subsequent evaluation should be based on observation of
the pressure-time waveform.27
Ventilator modes that deliver both volume-controlled
and pressure-controlled breaths often provide additional
information that is useful in evaluating adequate peak flow.
As seen in Figure 24 the peak flow of the mandatory
breath can be compared with the peak flow of the pressure
supported breath in pressure support ventilation. The peak
flow of the pressure supported breath is in part determined
by the patient effort. Under ideal conditions the peak flow
for both breath types should match. In this case the peak
flow of the mandatory breath is considerably less than the
peak flow of the pressure supported breaths, and needs to
be increased. In this example, further confirmation of the
inadequate peak flow during the volume-controlled breath Fig. 18. Airway pressure (Paw) waveforms during controlled mechan-
is provided by the dished out appearance of the corre- ical ventilation in a completely relaxed patient (top) and during a
triggered breath (middle). The shaded area in the bottom waveform is
sponding pressure waveform and the additional flow seen
the pressure-time product of the inspiratory muscles calculated as
in the middle of the flow waveform (circle in Fig. 24). the difference in area subtended by the Paw-time curve in the pres-
Current ventilators have fail-safe mechanisms that allow ence (middle) and absence (top) of inspiratory muscle activity.
patients to draw flow through the circuit if the power to the (Adapted from Reference 28.)

Fig. 19. These waveforms represent relaxed, passive breathing by a subject connected to a Bear 100 ventilator during intermittent
mandatory ventilation plus 2 cm H2O continuous positive airway pressure (PEEP). The circled breath is a mandatory volume breath with a
constant-flow pattern.
Fig. 20. Two-breath sequence during volume-controlled ventilation. The first breath is passive. During the second breath the subject exerted
additional inspiratory effort, which scooped out the airway pressure waveform.

Fig. 21. Two-breath sequence during volume-controlled ventilation, created in a laboratory setting, using a Servo 300A ventilator and a
Michigan Instruments test lung. Effort during the second breath was created by manually lifting the test lung. The shaded area represents
the pressure-time product associated with the additional simulated inspiratory effort.
Fig. 22. Three-breath sequence obtained with a Bear 1000 ventilator connected to Michigan Instruments test lung during volume-controlled
ventilation. Progressive increases in patient effort during breaths 2 and 3 were created by manually lifting the test lung. The dished-out
appearance of the airway pressure waveform illustrates the changes from the passive breath when flow does not meet patient demand.

Fig. 23. Evaluation of trigger threshold and patient effort. Progressive increases in patient effort are evidenced by the increasingly scooped
appearance of the airway pressure waveform (downward arrows). Trigger synchrony is evaluated by interpreting the beginning of the flow
waveform, and by the time relationship to the initiation of patient effort in the airway pressure waveform (upward arrows at the beginning
of the constant-flow pattern). Even though inspiratory effort progressively increased, the valve correctly opens after a small drop in airway
pressure. Inadequate peak flow, however, causes the dished-out appearance of the airway pressure waveform, as the patient exerts more
effort.
Fig. 24. Comparison of peak flow during a constant-flow mandatory breath (circled) and during pressure support breaths during synchro-
nized intermittent mandatory ventilation. The peak flow of the mandatory breath is substantially less than the peak flow associated with the
patient-oriented pressure support breath. The inadequacy of the ventilator peak flow is evidenced by the scooped-out appearance of the
airway pressure waveform (arrow) and the additional flow that the patient pulls through the demand valve in excess of the constant-flow
setting (bump in the middle of the constant-flow waveform).

Fig. 25. These waveforms illustrate inadequacy of ventilator flow while using the descending-ramp flow pattern. Upper panel: As flow decreases
during the latter portion of the breath, the patient demand for flow results in scooping of the airway pressure waveform (arrow). Lower panel: The
ventilator peak-flow setting was increased from 60 L/min to 120 L/min, which eliminated the scooped appearance of the airway pressure
waveform. P ⫽ airway pressure. (Courtesy of Kenneth D Hargett RRT, The Methodist Hospital, Texas Medical Center, Houston, Texas)
ventilator fails. In addition, some ventilators (eg, Bear

1000 and Servo 300A) allow the patient to draw additional
flow when the patient’s flow demand exceeds the venti-
lator flow settings.
Several studies indicate that the descending-ramp flow
pattern with volume-controlled ventilation, or the variable
descending-ramp flow pattern with pressure-controlled
ventilation, is preferable for patients with COPD and pro-
vides better ventilator mechanics, lower peak airway pres-
sure, better gas exchange, and less patient work.30,31 In
Fig. 26. These waveforms show a situation in which a change in the
some respects the descending-ramp flow pattern is similar
ventilator flow pattern caused positive end-expiratory pressure (auto-
to a pressure support breath: it has a high initial peak flow, PEEP). During the initial 3 breaths the constant-flow pattern gave
followed by a decrease to some terminal flow point. How- sufficient time for the patient to complete the exhalation to functional
ever, unlike the pressure support breath, in which the flow residual capacity (note the return of expiratory flow to zero prior to the
adjusts to patient demand, the descending-ramp flow pat- subsequent breath). After the change to the descending-ramp pat-
tern, inspiratory time increased to accommodate the set tidal volume,
tern with volume control is fixed and therefore needs to be because of the reduced flow over time, which reduces expiratory
carefully monitored for flow adequacy. The upper panel of time, and the patient developed auto-PEEP, as seen by failure of the
Figure 25 illustrates a patient condition in which the initial expiratory flow waveform to return to zero at the ends of those breaths.
peak flow setting under volume control was inadequate Also note the increase in peak airway pressure, which indicates the
and resulted in a concave appearance during the descend- development of trapped gas. (Courtesy of Kenneth D Hargett RRT,
The Methodist Hospital, Texas Medical Center, Houston, Texas)
ing-ramp portion of the flow waveform. A subsequent
increase in the peak-flow setting (lower panel of Fig. 25)
improved the appearance of the flow waveform. chrony. Figure 26 illustrates how a simple alteration in
Though changes in flow pattern influence flow syn- flow pattern can create auto-PEEP. In this case the change
chrony, they also have secondary effects on other portions in the flow pattern from constant to descending ramp
of the breath and may create additional types of asyn- slightly increased inspiratory time. With a fixed cycle time,

Fig. 27. Airway pressure (Paw), flow, and esophageal pressure (Pes) waveforms from a patient with chronic obstructive pulmonary disease,
ventilated with volume assist-control ventilation, with 2 inspiratory flow rates: 30 L/min and 90 L/min. With both flow rates, tidal volume was
kept constant (0.55 L). Ineffective (nontriggering) inspiratory efforts are indicated by arrows. Increasing the expiratory time (by increasing
inspiratory flow at constant tidal volume) decreased dynamic hyperinflation, which reduced the number of ineffective inspiratory efforts,
which increased the respiratory rate. (From Reference 2, with permission.)
the prolonged inspiratory time reduced the time alotted for the peak flow setting was increased (lower panel of Fig.
expiration, and resulted in air-trapping. Auto-PEEP can be 27), inspiratory time decreased, expiratory time increased,
positively identified in a flow waveform where expiratory and auto-PEEP decreased, which resulted in fewer missed
flow does not return to zero prior to the onset of the next trigger attempts. With modern ventilators the incidence of
breath. In addition, the peak airway pressure increases— ineffective triggering does not seem to differ between flow-
another indication of air-trapping. triggering and pressure-triggering systems,33 but shape-
In addition to flow patterns, VT and peak flow settings signal triggering shows promise for improving synchrony
also influence inspiratory and expiratory timing. This is for many patients with COPD.34
particularly important with patients who have severe air- Patients with asthma (Fig. 28) can suffer deleterious
flow limitation. In the literature there are examples of effects from large VT and flow-time relationships that re-
patients who were on fixed flow patterns and developed sult in hyperinflation and missed trigger attempts.32 Dur-
auto-PEEP.2,32 The upper panel of Figure 27 illustrates a ing one of the breaths (vertical lines in Fig. 28) much of
patient who had COPD and a low peak-flow setting that the neural inspiratory time is spent in pulling through the
resulted in air-trapping and missed trigger attempts. After auto-PEEP, such that the patient effort is nearly over be-

Fig. 29. Mean end-inspiratory lung volume (VEI) (above passive

Fig. 28. Airway pressure (Paw), flow, and esophageal pressure functional residual capacity) plotted against mean expiratory
(Pes) waveforms from a patient with severe obstructive lung time in patients with severe airway obstruction. The measure-
disease, ventilated on volume assist-control ventilation. With ments were obtained at 3 tidal volumes: 0.47 L, 0.88 L, and 1.44
this ventilation mode, every patient effort should trigger the L. Note the profound effect of VT and expiratory time on VEI.
ventilator to deliver a breath with a predetermined volume and Note also the values of VT and expiratory time associated with
flow waveform, so the mandatory rate should be set by the a safe range of VEI (ie, 1.4 L) (From Reference 32, with permis-
patient, while the tidal volume and mechanical inspiratory time sion.)
are determined by the ventilator. Note the substantial number of
ineffective inspiratory efforts (arrows). These missed trigger ef-
forts can be identified using the Paw, flow, or Pes waveform. An
abrupt decrease in Paw and Pes during expiration, and hesitation chodilators, by using the largest-diameter endotracheal tube
in expiratory flow, which are not followed by a mandatory breath, appropriate for the patient, and by reducing circuit resis-
indicate a missed trigger effort. Note also the considerable de- tance (eg, connectors and valves).32
lay between the beginning of inspiratory effort (first vertical line)
Dynamic hyperinflation may be identifiable in the pres-
and ventilator triggering (second vertical line). A substantial por-
tion of the inspiratory muscle pressure is needed to trigger the sure-time waveform (Fig. 30), although this requires ad-
ventilator, and, in some breaths, all the muscle pressure is dis- justing the scale on the time axis, or it may be displayed on
sipated to trigger the ventilator, so the neural inspiratory time the pressure-volume loop as an over-distention “beak” (Fig.
ends when the mandatory inspiratory time starts. In that situa-
31). The latter is more likely to display obvious changes in
tion there is major patient-ventilator asynchrony. Note also that
in some breaths, Paw is convex toward the time axis, which pattern, but is often missed because the clinician must
indicates that the flow from the ventilator is not meeting the select a different display option than the standard wave-
patient’s instantaneous flow demand. (From Reference 32, with forms. Clinically, the VT should be reduced until the beak
permission.)
on the pressure-volume loop disappears.
fore the ventilator inspiratory time begins. The presence of

hyperinflation, by delaying the ventilator trigger, imposes
a substantial delay between the beginning of patient effort
and the breath delivery. Expiratory time is further delayed
and results in subsequent missed trigger attempts. Though
this example does not specifically address adjustments to
the flow pattern, it does emphasize the importance of eval-
uating auto-PEEP and identifying missed trigger attempts
in the flow waveform.
VT also has important affects on hyperinflation. Figure
29 illustrates the impact of VT and mean expiratory time
on the amount of trapped gas in patients with asthma.
Larger VT and shorter expiratory time substantially in-
crease the amount of trapped gas. The volume of trapped Fig. 30. Airway pressure as a function of time during constant-flow
gas is significantly correlated with the incidence of baro- inflation in a patient with status asthmaticus and severe dynamic
trauma and hypotension in patients with asthma.35,36 Strat- hyperinflation. Note that the pressure curve is convex downward
(arrow), indicating that the system, because of dynamic hyperin-
egies to reduce dynamic hyperinflation include: (1) reduce
flation, approaches total lung capacity at the end of inspiration,
minute ventilation (ie, permissive hypercapnia), (2) in- during which compliance is relatively low. In this patient the intrin-
crease expiratory time by increasing inspiratory flow, and sic positive end-expiratory pressure was 17 cm H2O. (From Ref-
(3) decrease resistance to expiratory flow by using bron- erence 32, with permission.)

Fig. 31. Over-distention “beak” on a pressure-volume loop. In this example, volume in excess of 350 mL abruptly increases pressure,
indicating over-distention. VT ⫽ tidal volume. Pcirc ⫽ circuit pressure. (Courtesy of Kenneth D Hargett RRT, The Methodist Hospital, Texas
Medical Center, Houston, Texas)
Pressure Ventilation With Variable Flow sure-controlled ventilation, however, the peak flow is no
longer fixed, but is variable and depends on various fac-
Evaluation of flow asynchrony during pressure- tors, including; (1) set target pressure, (2) patient effort,
controlled ventilation also requires viewing the pressure- and (3) respiratory-system compliance and resistance. Of
time waveform to determine the adequacy of flow deliv- those, only the pressure can be set by the clinician. The
ery. As with volume-controlled ventilation, the flow pressure should be set based on the lowest pressure setting
delivery is assessed by evaluating the presence or lack of that achieves the desired VT. The main flow parameter that
concavity in the pressure-time waveform. During pres- can be adjusted during pressure-controlled ventilation is
Fig. 32. These waveforms illustrate pressure support breaths using different rise time (pressure slope, or rate of valve-opening) settings,
ranging from very slow (1) to very fast (5) valve opening, performed with a nearly constant or stable inspiratory effort (flow demand). The
airway pressure waveform appears scooped-out initially and then progresses to a more constant-pressure pattern as the valve setting is
changed to open faster. Breath 4 has the best valve-opening setting for these conditions. In breath 5 the valve opens a little too fast and
causes a slight pressure-overshoot early in the airway pressure waveform.

Fig. 33. Effect of minimum (mn), medium (md), and maximum (mx) rise times on trigger pressure-time product (T-PTP) during pressure
support ventilation (white bars) and pressure assist/control modes (black bars) with 5 ventilator brands. T-PTP decreased as rise time
increased, with all the ventilators, in both pressure support and pressure assist/control mode. (From Reference 7.)
the rate of valve-opening (also called rise time, pressure

slope, or flow acceleration). Each manufacturer has its
own algorithm to control the valve responsiveness or rate
of valve-opening, but the basic settings on the ventilator
either increase or decrease how rapidly the valve opens
from the initial closed position to the open position. In
more specific terms, under passive breathing conditions,
the rate of valve opening affects the time-to-return-trigger-
pressure-to-zero (D-B in Fig. 3) and the time for the pres-
sure to rise from zero to the set peak pressure. Figure 32
shows examples of how different rise time settings ad-
justed during active breathing affect the pressure, flow,
and volume waveforms.
Chatmongklochart et al analyzed various ventilators,
with different minimum and maximum rise-time settings.7
They evaluated the effect of rise time on the total time
delay, the trigger pressure, and the trigger pressure-time
product (Area 1 in Fig. 3). Slower rise times caused in- Fig. 34. Effects of rise time (pressure slope) on the work performed
creases in all of the above-named parameters, including per liter of ventilation (WI/L) and expressed as a percentage of the
the trigger pressure-time product (Fig. 33). They found values for work observed under spontaneous ventilation (SV). The
slope was modulated so that the same plateau pressure (15 cm
that “patient effort and WOB are affected by the ventila- H2O) was reached after a period ranging from 0.1 second (T 0.1) to
tor’s ability to meet patient peak inspiratory demand.”37,38 1.5 seconds (T 1.5). Each curve represents 1 patient (n ⫽ 12
During pressure-controlled ventilation the rise time should patients). The bold line indicates variation of the means. Five of the
be adjusted to meet the patient’s inspiratory flow demand curves are shorter than the rest because the last sequence could
and is ideally set when the pressure waveform has a min- not be performed with those patients. (From Reference 43, with
permission.)
imal negative deflection on the front end, a smooth and
rapid rise to near peak pressure (while avoiding pressure-
overshoot), and the appearance of a short plateau prior to
termination (almost-constant-pressure waveform)39 (see the patients with obstructive42 and restrictive43 lung disease
breath marked by an asterisk in Fig. 32). If the flow de- (Fig. 34) when rise time was reduced (rapid valve-open-
mand is not met, the pressure waveform is concave on the ing). When rise time is prolonged (slow valve-opening), it
front end and the patient performs unnecessary work, re- is easy to see the increase in patient work, demonstrated by
sulting in flow asynchrony. the area under the esophageal pressure waveform (see Fig.
Studies of flow asynchrony during pressure-controlled 35). Johnson et al reported similar changes in the esoph-
ventilation suggest that many patients require a rapid rise ageal pressure waveform and noted the dished-out appear-
time because of increased ventilatory demand.40 – 42 Bon- ance of the pressure waveform in a case study involving
marchand et al found reductions in inspiratory WOB in acute lung injury.39 Figure 36 illustrates a situation in which

Fig. 35. Representative flow, volume, airway pressure (Paw), esophageal pressure (Pes), and end-tidal carbon dioxide pressure (PETCO2)
waveforms from a patient with spontaneous ventilation (SV), and one undergoing pressure support ventilation (pressure support of 15 cm
H2O). The rise time was modulated so that the plateau pressure was reached after a time ranging from 0.1 second (T 0.1) to 1.5 seconds
(T 1.5). Each reduction of the pressure ramp slope was associated with an apparently dose-dependent progressive increase in Pes swings
(arrows). Tidal volume appeared to remain constant. (From Reference 43, with permission.)
Fig. 36. Waveform recorded by the freestanding respiratory mon- Fig. 37. These waveforms are from the same subject as the wave-
itor on postoperative day 9. The rise-time setting is 10%. Note the forms in Figure 36, in which the rise time was 10% (slow valve-
scooped-out appearance of the airway pressure (Paw) waveform opening). In the above figure, the rise time is 1% (rapid valve-
(arrows), which indicates inadequate flow. When the initial flow opening), which causes a much steeper slope in the beginning of
output is lower than patient demand, the rise in airway pressure the inspiratory flow waveform. The pressure support level is
may be delayed or prolonged, or in some case may prohibit at- achieved earlier in the inspiratory phase (arrow), and there is a
taining the set pressure support level. V̇ ⫽ flow. VT ⫽ tidal volume. pressure plateau. V̇ ⫽ flow. VT ⫽ tidal volume. Pes ⫽ esophageal
Pes ⫽ esophageal pressure. (Adapted from Reference 39.) pressure. (Adapted from Reference 39.)
the initial ventilator rise-time setting did not provide ade- valve-opening setting may be preferable.40 – 42 The pres-
quate flow for the patient’s flow demand (slow valve- sure-overshoot occurs when there is a mismatch be-
opening). The rise-time setting was increased to meet the tween the patient’s flow demand and the rate of flow
patient’s demand (Fig. 37), which improved the pressure- delivery determined by the rise-time setting (see Fig.
time waveform (pressure rises more rapidly to the target 38). Rapid rise time can also cause flow asynchrony,
pressure) and decreased the esophageal pressure swing. patient discomfort, and premature termination of inspi-
In contrast, there are both patient and ventilator con- ration. Premature termination can be caused by either of
ditions in which rapid valve-opening causes pressure- 2 mechanisms: (1) early in flow delivery, the initial
overshoot early in the breath, in which case a slower pressure-overshoot may exceed the target pressure and

Fig. 38. Rapid valve-opening (fast rise time) results in pressure-overshoot in the airway pressure waveform (arrows). In addition, the initial
flow in excess of patient demand creates a high peak flow and a steeper flow decrease, which can cause premature termination of
inspiration. (Courtesy of Kenneth D Hargett RRT, The Methodist Hospital, Texas Medical Center, Houston, Texas)
terminate inspiration as part of the secondary breath- of rise time, even during volume-controlled ventilation
termination criteria (pressure termination), or (2) late in (Fig. 40). In the example in Figure 40, the rise-time
the flow delivery, the flow-termination point may occur setting (inspiratory rise-time percent) was set at its low-
sooner (percentage of peak flow is now a higher flow- est point (ie, most rapid valve-opening setting, which
termination value because of the higher initial peak flow) can be accomplished only by depressing the knob and
(Fig. 39). The Servo 300A ventilator allows adjustment turning it to the zero position, which the manufacturer
Fig. 39. Airway pressure (above) and flow (bottom) waveforms during 2 different rise time settings. The faster rise time (second breath)
results in a higher peak flow and pressure-overshoot (arrow). In addition, the flow-termination criterion (percent of peak flow) is reached
sooner because of the higher peak flow, and the breath terminates sooner. I ⫽ inspiratory. (Courtesy of Kenneth D Hargett RRT, The
Methodist Hospital, Texas Medical Center, Houston, Texas)

Fig. 40. With these waveforms the rise-time (on the Servo 300A ventilator) during volume-controlled ventilation was set to its fastest position
(shortest rise time), which causes pressure oscillations early in the pressure waveform and also on the pressure-volume loop. On the Servo
300 ventilator the rise time can be set in any mode. Accessing the fastest rise-time setting requires depressing the setting knob and turning
it to the zero position, which the manufacturer does not recommend under normal conditions.
does not recommend under normal circumstances), which ciated with the inspiratory cycle. The remaining types
causes pressure oscillations early in the pressure wave- of asynchrony are associated with expiratory events.
form. These include premature or delayed breath termination,
Though adjustment of the rise time is considered fine- and problems associated with overlap of expiratory mus-
tuning of the flow parameter, it is fairly easy to accomplish cle activity into the inspiratory cycle and simultaneous
by observing the flow and pressure waveforms simulta- contraction. While the latter are difficult to evaluate
neously and adjusting the rise time to maximize the ap- without neural recordings, evaluation of breath-termi-
pearance of the waveform (almost square appearance of nation is possible with the use of the standard pressure
the pressure waveform, no concavity, and no overshoot; and flow waveforms, and it has also been documented
see asterisk in Fig. 32). In comparison to volume-con- with neural recordings.47,48 Figure 41 illustrates the dif-
trolled ventilation, the ability to more nearly match the ference between premature termination (ventilator cy-
patient flow waveform during pressure-controlled ventila- cles off before the end of expiratory-muscle neural ac-
tion, and the ventilator’s ability to increase or decrease tivity) and delayed termination (ventilator does not cycle
flow in response to patient demand are desirable traits that off until after expiratory-muscle activity is initiated).
ultimately improve flow synchrony.
In general, the pressure-controlled modes (pressure sup-
Delayed Termination
port and pressure control) are better capable of meeting
inspiratory demand than is volume-controlled ventila-
tion.44,45 In addition, dual-control modes, which combine Parthasarathy et al studied delayed termination in a group
the attributes of pressure limiting and volume control, might of healthy subjects in whom airflow limitation was simu-
improve patient-ventilator synchrony.11,46 lated with a Starling resister.47 As seen in Figure 42, an
increase in pressure support resulted in a greater number
Termination Asynchrony (Phase 3) of missed trigger attempts. In evaluating the data, the non-
triggered attempts were preceded by breaths with larger
The first 2 types of asynchrony (missed trigger at- peak flow, higher VT, and prolonged inspiratory time. Non-
tempts or trigger delay and flow asynchrony) are asso- triggering attempts involved weaker inspiratory efforts

Fig. 41. The relationship of neural expiratory time to ventilator

expiratory time was assessed by measuring the phase angle, ex-
pressed in degrees. If neural activity began simultaneously with
the ventilator, the phase angle (0) was zero. Neural activity begin-
ning after the offset (termination) of inflation by the ventilator re-
sulted in a positive phase angle (60 degrees for subject 1). Neural
activity beginning before the offset of inflation by the ventilator
resulted in a negative phase angle (⫺45 degrees for subject 2).
(From Reference 48, with permission.)
Fig. 43. Waveforms of flow, airway pressure (Paw), and transversus

abdominis electromyogram in a critically ill patient with chronic
obstructive pulmonary disease receiving pressure support of 20
cm H2O. Expiratory muscle activity (vertical dotted line) began
when mechanical inflation was only partly completed. Note there
is also a small airway pressure spike near the end of mechanical
inflation, which coincides with the patient’s neural expiratory ac-
tivity. (From Reference 48, with permission.)
Hering-Breuer reflex, decreases respiratory motor output49

and therefore decreases inspiratory pressure-time product.
In subjects in this study, “the continuation of mechan-
ical inflation into neural expiration not only directly coun-
tered expiratory flow, it also decreased the time available
Fig. 42. Phase angle (see Fig. 41) between neural and mechanical for unopposed expiratory flow.”47 This leads to an in-
expiratory times before triggering (closed circles) and nontrigger- crease in elastic recoil, which necessitates a greater in-
ing (open circles) inspiratory attempts. At pressure support (PS) of spiratory effort to trigger the ventilator.50,51
10 cm H2O and 20 cm H2O, the phase angle before nontriggering Similar results are seen in patients with COPD (Fig.
attempts exceeded that before triggering attempts, indicating that
neural expiratory time during late mechanical inflation preceded 43).47 Though the neural waveform verifies the presence
the onset of mechanical expiratory time and was longer before of expiratory-muscle activity prior to the end of mechan-
nontriggering attempts than before triggering attempts. (From Ref- ical inflation, the consequences of the expiratory effort can
erence 48, with permission.) be seen in the flow and airway pressure waveforms. The
airway pressure waveform shows a small spike near the
(smaller pressure-time product) than did efforts that trig- end of the inhalation. The flow waveform drops dramati-
gered the ventilator. The decreased inspiratory pressure- cally at the end of the breath, indicating pressure termina-
time product might have been caused by increased lung tion. Jubran et al52 also noted that 5 of 12 patients with
volume, which shortens the inspiratory muscles and thus COPD appeared to recruit expiratory muscles during me-
decreases inspiratory pressure generation.47 Increased lung chanical inflation. In that study they used Pes measure-
volume also increases vagal afferent traffic, which via the ments (as opposed to direct expiratory-muscle electromyo-

Fig. 44. These waveforms illustrate a subject being ventilated with a pressure support of 5 cm H2O. The subject’s neural timing precedes
the end of mechanical inflation and results in a pressure spike (large arrow) on the airway pressure waveform. Also note the rapid decline
in the inspiratory flow waveform near the end of the breath (small arrows) as a result of the subject’s expiratory effort.
gram recordings) to evaluate expiratory-muscle activity. the target pressure and the end of mechanical inflation. In
Parthasarathy et al47 used electromyography to confirm pressure-controlled modes, however, the inspiratory time
similar observations in normal subjects. is set by the clinician. In this case, subsequent reduction in
Delayed termination generally results in dynamic hyper- inspiratory time removed the pressure spike and the zero-
inflation, which causes trigger-delay and increases the num- flow plateau. Figure 46 illustrates another case study in-
ber of missed trigger attempts. Though there may be differ- volving delayed termination in the pressure-control mode.
ences between patient groups, most patients seem to have Inspiratory time is prolonged excessively, and the pressure
rather weak compensatory responses to acute delays in breath- waveform illustrates repeated expiratory attempts by the
termination52,53 and generally do not make acute changes in patient.
their expiratory timing following a single inspiration. Data from diseased subjects, with a variety of disorders,
Even in normal healthy subjects the effects of delayed indicate that inspiratory times are often in the range of 1
termination can be assessed by carefully evaluating the second or less.54 Though there are clearly instances in
pressure and flow waveforms. Figure 44 illustrates pres- which variations occur, the less-than-1-second guideline
sure and flow waveforms during pressure support ventila- should be used as an approximate starting point for eval-
tion of a healthy respiratory care student. Those wave- uating and setting inspiratory time.47,54 During pressure-
forms demonstrate the same delayed breath-termination controlled ventilation the initial inspiratory time can be set
characteristics as in the COPD patient noted above. There with the less-than-1-second guideline, and then subsequent
is an obvious pressure spike near the end of the breath, adjustments should be based on the time for the inspiratory
which coincides with a rapid decline in flow, indicating flow waveform to decay to zero, but not beyond, and to
the subject’s attempt to exhale. A similar pattern is seen in prevent a pressure spike near the end of inspiration. Dur-
the waveform in Figure 45, which was obtained during ing pressure-support ventilation the expiratory sensitivity
pressure-regulated volume-control ventilation (on a Servo can be adjusted within this range, while fine tuning can
300A ventilator). Again, there is an obvious pressure spike occur in 2 directions: if the breath is too long, there will be
at the same time as the zero-flow plateau in the flow a pressure spike near the end of the breath; if the breath is
waveform. The zero-flow plateau indicates achievement of too short, the patient may continue to inhale, resulting in

Fig. 45. Waveforms from a normal subject ventilated with pressure-regulated volume control on a Servo 300A ventilator. The subject’s
expiratory effort begins just prior to the end of the mechanical inspiratory time, which causes pressure spikes (arrows). Also note the small
inspiratory zero flow plateau at the end of the inspiratory flow waveform, which indicates that flow into the lung has stopped just prior to
mechanical expiration. In pressure-controlled modes the inspiratory time is set on the ventilator, and in this instance the ventilator
inspiratory time setting needs to be reduced slightly.
effects of different inspiratory termination criteria (1%,

5%, 20%, 35%, and 45% of peak flow) during pressure
support ventilation. In Figure 47 the waveforms in the
upper 2 panels were obtained with the 5%-of-peak-flow
termination criterion, and the waveforms in the lower 2
panels were obtained with the 35% (left) and the 45%
(right) criteria, both of which cause earlier termination
than the 5% criterion. Note several differences between
the waveforms. In the flow waveform, earlier termination
Fig. 46. Airway pressure and flow waveforms from a patient ven-
causes an abrupt initial reversal in the expiratory flow
tilated with a Puritan Bennett 7200 ventilator, in pressure-control waveform (the expiratory flow slope has a rapid return to
mode. Note the multiple pressure spikes (arrows), which indicate zero), indicating the continuation of patient effort. Evalu-
expiratory efforts, and the appearance of the zero-flow plateau ation of the airway pressure waveform also indicates an
beginning at mid-inspiration. The initial inspiratory-time setting on abrupt drop from the peak pressure toward baseline, again
the ventilator was far in excess of the patient’s neural timing, and
was subsequently reduced. Paw ⫽ airway pressure. PCV ⫽ pres-
associated with the continuation of patient inspiratory ef-
sure control ventilation. (Courtesy of Kenneth D Hargett RRT, The fort (concave appearance rather than a normal gradual de-
Methodist Hospital, Texas Medical Center, Houston, Texas) cay). Similarly, there is a continued drop in the esophageal
pressure waveform, even after inspiratory flow termina-
tion, which indicates that muscular effort has not yet
double-triggering (also known as a “stacked breath”; see stopped. During the exaggerated condition (termination at
the section below on early termination). During volume- 45% of peak flow) the continued patient inspiratory effort
controlled ventilation the less-than-1-second guideline can results in 1 incidence of double-triggering (the circled
be used to determine the peak inspiratory flow necessary breaths in Fig. 47). Analysis of the waveform (Fig. 48)
to achieve the desired VT while keeping inspiratory time indicates that early termination substantially reduced VT,
around 1 second. Subsequent fine-tuning should be based increased respiratory rate, decreased inspiratory time, and
on interpretation of the pressure waveform. increased WOB.
Premature Termination Expiratory Asynchrony (Phase 4)
Premature breath-termination also has deleterious ef- We have discussed termination asynchrony as a sepa-
fects and causes asynchrony in patients with acute respi- rate consideration to emphasize the importance of per-
ratory distress syndrome. Tokioka et al55 evaluated the forming a stepwise analysis of the breathing pattern. The

Fig. 47. Left Panel: Flow (V̇), volume (V), airway pressure (Paw), and esophageal pressure (Pes) waveforms with termination criteria (TC) of 5% and
35% of peak flow, during ventilation with pressure support of 10 cm H2O. With TC 5% the breathing pattern was regular. Tidal volume was 390
mL and respiratory frequency was 17 breaths/min. The negative deflection of Pes during inspiration was minimal. With TC 35%, tidal volume
decreased to 281 mL, and respiratory frequency increased to 23 breaths/min. The inspiratory flow terminated despite continuous negative
deflection of Pes. Work of breathing increased from 0.20 J/L with TC 5% to 0.32 J/L with TC 35%. The arrows indicate continued patient
inspiratory effort on the expiratory flow waveform (convex pattern) and the airway pressure waveform (concavity). Right panel: TC 5% versus TC
45% during ventilation with pressure support of 10 cm H2O, with case 2. With TC 5%, inspiratory flow terminated simultaneously with the
cessation of the patient’s inspiratory effort, estimated by Pes. In contrast, premature termination with double-breathing (circled) occurred with TC
45%. Work of breathing also increased, from 0.42 J/L with TC 5% to 0.64 J/L with TC 45%. Note the larger Pes deflection during TC 45%. Also
during TC 45% note the more pronounced changes (arrows) in the expiratory flow curve and the expiratory portion of the airway pressure
waveform, caused by continued patient inspiratory effort despite early termination of the mandatory breath. (From Reference 55, with permission.)
remaining portion of the breath to consider is the expira- Shortened expiratory time creates the potential for air
tory time and the potential clinical consequences of short- trapping and auto-PEEP, which can cause trigger asyn-
ened or prolonged expiratory time. chrony because of the additional effort required to pull
Shortened expiratory time has major clinical implica- through the auto-PEEP to reach the trigger thresh-
tions because of the risk of causing auto-PEEP. Prolonged old.21,47,59,60 Breaths preceding missed breaths typically
expiratory time is of little consequence, unless the expi- have longer inspiratory times and shorter expiratory times,
ratory time is so long as to cause hypoventilation. Expi- and are associated with auto-PEEP. In completing the breath
ratory asynchrony can occur in conditions in which there analysis it is perhaps circuitous to note that the final con-
is delay in the relaxation of the expiratory-muscle activity sideration of auto-PEEP has as one of its main impacts the
prior to the next mechanical inspiration47 or overlap be- creation of trigger asynchrony, and that each of the fol-
tween expiratory and inspiratory muscle activity,56 –58 but lowing portions of the breath (inspiratory flow and termi-
those conditions are verified with neural measurements nation) also have as a consequence of asynchrony the cre-
and are beyond the scope of our discussion about use of ation of auto-PEEP. In other words, flow patterns that
the standard ventilator waveforms to evaluate patient-ven- increase inspiratory time (eg, lower peak flow during con-
tilator synchrony. trol ventilation, switch from constant-flow to descending-

tion. 3. Auto-PEEP is a common cause of failed attempts

and should be routinely evaluated. 4. Auto-PEEP can be
identified in the expiratory flow waveform.
Recommendations. 1. Including the trigger portion of

the signal (figure-8) on the pressure-volume loop would
help clinicians evaluate trigger effort. 2. Including a scrol-
lable vertical line in the graphics package would help cli-
nicians evaluate the correlation between pressure and flow
waveforms and the synchrony of patient effort with initi-
ation of ventilator flow. 3. Enhanced graphics capabilities
should be available to allow clinicians to better analyze
information (eg, automate calculations).
Flow Asynchrony (Phase 2)
Evaluating Flow Asynchrony During Volume-Con-

trolled Ventilation. 1. Inadequate flow is evidenced by
a scooped-out appearance on the pressure waveform, and
in some instances by observation of additional flow in the
flow waveform (eg, additional flow from the demand valve).
2. To evaluate flow adequacy, the clinician needs to be
familiar with the normal, relaxed, pressure waveforms as-
sociated with the various flow options.29 3. Peak flow is
Fig. 48. Tidal volume (VT), respiratory frequency (f), inspiratory time frequently set too low, which prolongs inspiratory time
(TI), and work of breathing (WOB) with 5 different termination cri- and decreases expiratory time, causing auto-PEEP and asyn-
teria (TC) during pressure support ventilation of 8 patients. VT was chrony. 4. Both peak flow and the flow pattern affect flow
significantly lower with TC 45% than with TC 1%. With increasing asynchrony. 5. Careful evaluation of the pressure wave-
TC, f steadily increased and TI markedly decreased. WOB was
significantly higher with TC 35% and TC 45% than with TC 1%.
form may reveal over-distention, which should be con-
(From Reference 55, with permission.) firmed with the pressure-volume loop.
Evaluating Rise Time. 1. Rise time can be evaluated by

ramp flow, inadequate pressure slope during pressure-con- observing the pressure and flow waveforms. 2. Usually the
trolled ventilation, termination criteria that prolong pressure waveform should achieve near target pressure
expiratory time during pressure support or pressure-con- early in the inspiratory cycle. Short (fast) rise time may
trol) or decrease expiratory time can cause auto-PEEP. In cause a pressure spike or pressure oscillations near the
addition, delayed flow termination offsets neural timing beginning of the pressure waveform. 3. The flow wave-
and reduces expiratory time, which can also create auto- form should smoothly reach the peak flow and then ap-
PEEP. propriately decrease. 4. In general, faster rise time should
reduce patient WOB.
Summary
Termination Asynchrony (Phase 3)
Asynchrony is an important and common problem that
can occur at several points in the breathing cycle. Con- Delayed Termination. Delayed breath-termination is ev-
ceptually, we have divided the breath into 4 phases to idenced by a pressure spike at the end of the breath and
simplify the analysis of patient-ventilator asynchrony. rapid decrease in the flow, which can cause subsequent
failed trigger attempts.
Trigger Asynchrony (Phase 1)
Premature Termination. Premature breath-termination
1. Trigger asynchrony is fairly easy to identify on the can be identified on the pressure waveform, which will
flow and pressure waveforms. 2. The flow waveform in show a post-termination concavity (indicating continued
particular should be evaluated to detect failed trigger at- patient effort) and on the flow waveform, which will show
tempts, and it should be correlated with patient observa- prolonged high flow during the breath, followed by rapid

deceleration and a convex pattern in the expiratory flow 13. Younes M. Proportional assist ventilation. In: Tobin MJ, editor. Prin-
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Discussion the ventilators I know of, there is no patient to breathe through the circuit in
way you can breathe through that valve. case the machine shut down.
Sanborn: I’m somewhat confused
about the concept of breathing through Nilsestuen: You are absolutely right. Benditt: This harkens back to Dean
the demand valve. In the past there was Modern ventilators have reduced the pa- Hess’s “eyeball test.” If the patient seems
an actual demand valve—a scuba-type tient’s ability to do that. The sample to be synchronous with the ventilator, if
valve. In today’s ventilators there is no waveform that this refers to is from the you look at the flow waveform, will you
equivalent of that. The valve either trig- Bear 1000. In this ventilator there was a pick up abnormalities that you would
gers or it doesn’t trigger, and in most of backup demand valve that allowed the not suspect with the eyeball test?

Nilsestuen: If you carefully evalu- physical examination I’m going to about the experienced practitioners he
ate the flow waveform? Is that what look at the flow waveform to make has had in his classes who have come
you’re asking? Or does the eyeball test sure that things are OK here.” Person- back for advanced training, and how
mean observing the patient to deter- ally, I would do as you say—just ex- confident and familiar they are with
mine if he or she is synchronous with amine the patient, and if there’s a prob- all of these things, but how poorly they
the ventilator? lem then investigate it with these tools. do on actual examinations that reflect
But if it’s the other way around, then their understanding of what they do.
Benditt: No. Say I go to the bedside I might have to change my practice It’s been my observation for a long
and I look at the patient, and the pa- and say that to maximize synchrony I time that clinicians— critical care
tient looks relaxed, isn’t using acces- should include the flow waveform as nurses for example—are often very fa-
sory muscles, the abdominal muscles part of my routine rounds. Sounds like miliar and comfortable with all the he-
aren’t contracting, and everything we’ve got a little difference of opin- modynamic data they deal with, but
looks good to me as a clinician. Then ion as to whether that’s part of the may have incomplete understanding
I turn on the flow waveform. Will I eyeball test. of what those data represent physio-
see these things popping out at me logically and what they actually mean.
that I didn’t suspect? Nilsestuen: My sense is that there Likewise, physicians who have been
are some very obvious things that you in practice for a while may have de-
Nilsestuen: My take on that is that can see the patient do. But, for in- veloped routines and familiarity and
sometimes, yes, you will see some stance, if the neural timing is off just comfort and fluency with the data that
things that you didn’t suspect, because a little bit, and there’s just a tiny little they deal with every day, but may not
the patient is not yet exhibiting a strong bump in the pressure waveform, you interpret that data in a manner consis-
enough apparent effort or obvious won’t see that just by looking at the tent with our current understanding of
muscular activity that counters what patient, because the patient will look what it ought to mean. So I think this
the ventilator is doing. The subtleties fairly relaxed, whereas in fact he’s just is a very complex issue that involves
start showing up in the waveforms be- starting to recruit muscular activity both the clinician as subjective observ-
fore it’s obvious at the bedside. right at the end. That’s fine-tuning, er—the eyeball test— but also knowl-
definitely, but, I think looking at the edge of the technical aspects of what
Hess: Regarding what Josh Benditt graphics makes asynchrony very ap- the waveforms are telling us. I think
just brought up, I teach the respiratory parent, and then you can document neither of them is 100% the right an-
therapists, fellows, residents—anyone that there is a subtlety there that may swer, and they may sometimes be in
who will listen to me—to look at the improve patient comfort. conflict with one another.
patient, listen to the ventilator, and un-
derstand the physiology. I teach them to Pierson:* I think this stuff is pretty Hess: I am reminded, David, of a
look at the patient and listen to the ven- hard. I’m hearing Dean say that the picture that you published in one of
tilator, and if you see that the patient is eyeball test is valuable, and that how Martin Tobin’s books,1 which shows
making inspiratory efforts and you hear the patient looks in general should be the respiratory therapist peering at the
no response from the ventilator, there’s your overall guide as to how things ventilator, and the nurse peering at the
auto-PEEP. Then look for chest recoil, are going. But I’m also hearing Jon monitor, and the residents all looking
and if you see that the thorax is still saying that you can see things on the at the laboratory results, and nobody’s
recoiling when the next breath starts, graphics displays that are early warn- looking at the patient!
there’s auto-PEEP—the same thing ings of important things you haven’t
you’ll see on the flow waveform. So picked up by your observation. Now,
first look at the patient and listen to the I suspect that Jon would agree that REFERENCE
ventilator, then look at the graphics and there are things that one might see on
do all these other assessments to try to the waveforms that are not clinically 1. Pierson DJ. Goals and indications for mon-
itoring. In: Tobin MJ, editor. Principles and
understand the underlying physiology important. On the other hand, though, practice of intensive care monitoring. New
that is producing the clinical problem. the eyeball test depends very much on York: McGraw-Hill; 1998:33–44. [Figure
So, personally, I like graphics a lot, but whose eyeball it is. At the very begin- 2–2 on page 40]
I still rely a lot on the eyeball test. ning of his presentation Jon told us
Campbell: I agree with what you
Benditt: I think the reason that’s just said. I think it’s very important.
important, I would say, is because I * David J Pierson MD FAARC, Division of The patient’s appearance may lead you
don’t routinely on rounds go to the Pulmonary and Critical Care Medicine, Univer- to look at the graphics to diagnose
bedside and say, “OK, as a part of my sity of Washington, Seattle, Washington. and maybe fine-tune, but certainly with

advanced settings (such as rise time Hess: Call me old-fashioned. I look not forget that the primary setting is
and expiratory cycle sensitivity or ter- at graphics a lot and I like graphics a the pressure control, and the setting of
mination criterion), there’s no way you lot, but I have many times set PEEP pressure control is going to affect the
can set those appropriately just by your with patients who have auto-PEEP by flow waveform, or whatever wave-
view of what the patient’s doing. With simply looking at the patient, looking form you decide to look at. So what
lots of the graphs that Jon showed, if for failed triggering efforts, and just we really need is some tool that would
you didn’t have the line to line it up. . . . turning up the PEEP until every in- tell us if we have the base setting cor-
So I would never think you could put spiratory effort triggers the ventilator. rect before we take that next leap to
your hand on the patient’s chest or the secondary settings. The volume-
diaphragm and put your other thumb Pierson: But that’s your eyeball, support slides that you showed were
on the graphic and say, “Ah-ha, I think Dean, and not necessarily any random classic; they were showing all the
we’re in synchrony.” I don’t think eyeball. missed triggers. Well, maybe they just
that’s a possibility, and I think you didn’t have a high enough volume set.
really need those graphics to perfectly Harris: This sort of reminds me of Maybe it wasn’t the cycle criterion
set it. Respiratory therapists ask what the physical examination versus, say, that was the problem.
to do with the ventilator’s expiratory echocardiography for the heart. If you
sensitivity setting and I tell them to have a very experienced person who Benditt: I have a comment about
take the default, and if you see a pres- can understand what’s going on or has
Dr Pierson’s question, “Whose eye-
sure spike, adjust it. That’s the prob- a lot of experience looking at a pa-
ball is it?” If you think about it, it is
lem; we don’t have the equivalent of a tient, then the physical examination is
much more common to teach the
PDR [Physicians Desk Reference] for very helpful. If you have somebody
physical examination. Maybe it’s eas-
the ventilator that would tell us, “if who is not that experienced, it might
ier to get people to understand what
this, then that,” and “this is the dose,” not be so helpful.
muscle effort is in a patient who is
and “this is how to do it.” Jon, you described asynchrony as 2
asynchronous with the ventilator than
pumps that are not working together,
Nilsestuen: Another example of not in harmony, and I’m thinking that it is to evaluate waveforms, set up the
something that is far better done using we have a lot of information about line to look at the waveform overlap,
the graphics than with just the visual one of the pumps, the ventilator, but and so forth. I think you need at least
technique of looking at the patient is we don’t have a lot of information as much, and probably more, exper-
setting the correct inspiratory time dur- about what’s driving the human pump. tise to look at the waveforms as to
ing pressure-controlled ventilation. Should we be using things that Jon look at the muscle function at the bed-
There’s almost no way you can do was talking about? Should we be look- side. So, unless you are going to have
that visually by just looking at the pa- ing at diaphragm function? Should we an echocardiogram or have the thera-
tient, but it’s very easy to do if you be looking at neural time? Is it over- pist or some expert person do a daily
understand the graphics and you just kill, or would it be helpful to have that analysis of these waveforms for you
look at the flow waveform. Because information to synchronize the 2 and then put it in a report and send
then you can see the plateau if it’s too pumps? it to you, I think it’s probably better
long, you can see it chop off if it’s to teach them the physical examina-
terminating too soon. That’s maybe Campbell: We’re spending an aw- tion.
one of the best examples where it is ful lot of time talking about secondary
very clear that the graphics have a huge settings, such as setting the inspira- Hess: Glad to know I’m not the only
advantage. tory time during pressure control. Let’s old curmudgeon in the room.

Identify Patient-Ventilator Asynchrony

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Using Ventilator Graphics to Identify Patient-Ventilator Asynchrony

Jon O Nilsestuen PhD RRT FAARC and Kenneth D Hargett RRT

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Table 1. Factors That Affect Patient-Ventilator Synchrony

In a recent Joint Commission on Accreditation of Health

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Fig. 4. Flow and pressure waveforms from a patient during assist-

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Fig. 7. Graded increases in pressure support cause a decrease in

(high metabolic rate, high PaCO2, reduced sedation, reduced

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The preceding breaths had a shorter total-breathing-cy-

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Fig. 11. Flow-time waveform from a patient receiving intermittent

airway pressure, making it easier for the patient to achieve

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flow-triggering (Fig. 16). Auto-triggering was more Flow Asynchrony (Phase 2)

The adequacy of flow during volume-controlled venti-

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exercise intensity, the greater the flow demand. As the

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ventilator fails. In addition, some ventilators (eg, Bear

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Fig. 29. Mean end-inspiratory lung volume (VEI) (above passive

fore the ventilator inspiratory time begins. The presence of

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the rate of valve-opening (also called rise time, pressure

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Fig. 41. The relationship of neural expiratory time to ventilator

Fig. 43. Waveforms of flow, airway pressure (Paw), and transversus

Hering-Breuer reflex, decreases respiratory motor output49

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effects of different inspiratory termination criteria (1%,

Premature Termination Expiratory Asynchrony (Phase 4)

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tion. 3. Auto-PEEP is a common cause of failed attempts

Recommendations. 1. Including the trigger portion of

Flow Asynchrony (Phase 2)

Evaluating Flow Asynchrony During Volume-Con-

Evaluating Rise Time. 1. Rise time can be evaluated by

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