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PEEP
time
No active breathing
Treats lung as single unit PIP
resistance
flow
Pplat
end-inspiratory
alveolar pressure
compliance
tidal volume
PEEP
Nilsestuen, Respir Care 2005; 50:202-232
Pressure (cm H2O) Volume (mL) Flow (L/min)
PIP
Pplat 30 cm H2O
Decreased with:
• mainstem intubation • tension pneumothorax
• congestive heart failure • pleural effusion
• ARDS
• atelectasis • abdominal distension
• consolidation • chest wall edema
• fibrosis • thoracic deformity
• hyperinflation normal 100 mL/cm H O
2
ΔPeso ≈ ΔPpl
Ccw = VT/ΔPeso
= 350 mL/5 cm H2O
= 70 mL/cm H2O
Inhalation Exhalation
positive
mm Hg
pressure
18
ventilation
Inhalation Exhalation
mm Hg
spontaneous 18 Inspiratory muscle effort
breathing
10
PIP PIP
pressure
auto PEEP
set PEEP
time
auto-PEEP of
5 cm H2O by
occlusion
technique
sensitivity sensitivity
-1 cm H2O -1 cm H2O
auto-PEEP auto-PEEP
10 cm H2O 3 cm H2O
PEEP PEEP
10 cm H2O 10 cm H2O
time
0
auto-PEEP
exhalation
1
0 flow
(L/s)
0.8
volume
0 (L)
30
Paw
(cm H2O)
0
20
Peso
0 (cm H2O)
estimation of missed
auto-PEEP trigger effort
Volume Volume Waveform
leak
time
1.6
normal
volume above FRC (liters)
1.2
ARDS
0.8
upper inflection
point
0.4
lower inflection
point
0
0 10 20 30 40
airway pressure (cm H2O)
Issues with PV Curves
• Requires sedation and often paralysis
• Difficult to identify “inflection points”
Harris et al, AJRCCM 2000; 161:432
• May require esophageal pressure to separate lung
from chest wall effects
Mergoni et al, AJRCCM 1997; 156:846
Ranieri et al, AJRCCM 1997; 156:1082
• Deflation limb may be more useful than inflation limb
Holzapfel et al, Crit Care Med 1983; 11:561
Hickling, AJRCCM 2001; 163:69
• Pressure-volume curves of individual lung units
unknown
Hickling, AJRCCM 1998; 158:194
Dhand, Respir Care 2005; 50:246
Summary
• Assessment of mechanics is useful in
mechanically ventilated patients: PIP, Pplat,
auto-PEEP, Ccw, Pdi
• Assessment of mechanics provides insights
into the pathophysiology of the lungs
Pressure
time
time
Flow
Who’s Watching the Patient?