Chapter 23. Airway Volumes, Flows, & Pressures

Chapter 23
Airway Volumes, Flows, and Pressures

P. 729

Definitions
Compl i ance: Rati o of a change in volume to a change in pressure. It i s a
measure of di stensi bi l i t y and is usual l y expressed i n mi l l i l i t ers per centi meter
of water (mL/ cm H
2
O). Compl i ance commonl y ref ers t o the l ungs and chest
wal l . Breathing system components, especial l y breathing tubes and t he
reservoi r bag, al so have compl i ance.
Expi ratory Fl ow Rate: Rate at whi ch gas is exhal ed by t he pati ent expressed
as volume per uni t of ti me.
Expi ratory Fl ow Ti me: Ti me bet ween t he begi nning and end of expi rat ory f l ow
(Fi g. 23.1).
Expi ratory Pause Ti me: Ti me f rom the end of expi rat ory f low t o the start of
i nspi ratory f low (Fi g. 23. 1).
Expi ratory Phase Ti me: Ti me bet ween t he st art of expi ratory f l ow and the
start of i nspi ratory f low. It i s t he sum of t he expi ratory f low and expi ratory
pause ti mes (Fi g. 23. 1).
I nspi ratory Fl ow Ti me: Period between the begi nni ng and end of i nspi ratory
f low (Fi g. 23.1).
I nspi ratory Pause Ti me: That porti on of t he i nspi ratory phase ti me during
whi ch the lungs are hel d i nf l ated at a fi xed pressure or vol ume (i .e., the t i me
of zero f l ow (Fi g. 23.1). I t is al so cal l ed the i nspi ratory hol d, i nf lati on hol d,
and i nspi ratory pl ateau.
I nspi ratory Phase Ti me: Ti me between the start of i nspi rat ory f l ow and the
beginni ng of expi ratory f l ow (Fi g. 23.1). I t is t he sum of the i nspi ratory f low
and i nspi ratory pause t i mes. The i nspi ratory pause t ime:i nspi rat ory phase
t i me (T
I P
:T
I
) may be expressed as a percentage.
I nspi ratory:Expi ratory Phase Ti me Rati o (I : E rat io): Rati o of the i nspi ratory
phase ti me to t he expi ratory phase t ime. For exampl e, an I :E rati o of 1:2
means that the i nspi rat ory phase t i me i s one t hi rd of the venti latory cycl e
t i me.
I nspi ratory Fl ow Rate: Rat e at whi ch gas f l ows i nto the pat ient expressed as
volume per uni t of t i me.
Mi nute Vol ume: Sum of al l ti dal volumes wi t hi n 1 mi nute.
Peak Pressure: Maximum pressure duri ng the i nspi rat ory phase t i me (Fi g.
23.1).
Pl ateau Pressure: Rest ing ai rway pressure duri ng the i nspi ratory pause.
There i s usual l y a loweri ng of ai rway pressure f rom peak pressure when
t here i s an i nspi ratory pause (Fi g. 23. 1). Thi s l ower pressure i s cal led the
pl at eau pressure.
Posi t i ve End-expi ratory Pressure (PEEP): Posi t ive pressure i n the ai rway at
t he end of exhal at ion.
Resistance: Rati o of the change in dri vi ng pressure to t he change i n f l ow
rate. It i s commonly expressed as centi meters of water per l i ter per second
(cm H
2
O/L/second).
Ti dal Vol ume: Vol ume of gas enteri ng or l eavi ng the pati ent during t he
i nspi ratory or expi ratory phase ti me, respect ively.
Venti latory (Respi ratory) Rate or Frequency: Number of respi ratory cycl es
per uni t ti me, usual l y per mi nut e.
Work of Breathing: Energy expended by t he pati ent and/or venti lat or t o move
gas i n and out of the l ungs (1). I t i s expressed as the rati o of work to vol ume
moved, commonl y as j oules per l i t er. It i ncludes both the work needed to
overcome the el asti c and f low-resi stive f orces of the both respi ratory system
and apparatus.

View Figure

Figure 23.1 Flow, volume, and pressure curves from a
ventilator that produces a rectangular inspiratory flow wave.
A: This represents controlled ventilation with no inspiratory
pause. The end-inspiratory pressure will equal the peak
pressure. B: With an inspiratory pause, there is a decrease
from peak pressure to a lower plateau pressure. C: This
illustrates the effect of continuing fresh gas flow during
inspiration. The inspired volume increases, and the peak
pressure falls, then rises.

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General Considerations
The Ventilatory (Respiratory) Cycle
Ai rway pressure wi t h controll ed venti l at ion i s shown i n Fi gure 23.1. There i s a ri se
i n pressure wi t h no preceding negat ive pressure. A f ast rise to peak pressure
suggests too hi gh a f l ow. The peak pressure wi l l i ncrease i f ti dal vol ume,
i nspi ratory f low rate, or resi stance i ncreases or compl iance decreases. A decrease
i n peak pressure may resul t f rom a l eak, spontaneous i nspi ratory eff ort by the
pati ent , a decrease in resi stance, or an i ncrease i n compl i ance.
Fi gure 23. 1B shows t he respi ratory cycle wi t h an i nspi ratory pause. If the pause i s
l ong enough, a plateau pressure wi l l occur at the end of i nspi rati on. The pl ateau
pressure i s usual l y preceded by a hi gher peak pressure.
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Pl ateau pressure depends on t i dal vol ume and the total stat i c compl i ance but is
i ndependent of resi st ance (2).
Compliance and Resistance
I n t he past, compl i ance and resistance measurements duri ng anesthesi a were
di ff i cul t and i nvolved bul ky apparatus. They can now be measured accuratel y on a
real -t ime basi s wi t h rel at ivel y compact equipment.
Compliance
Compl i ance measurement may be dynamic or stati c. Dynami c compl i ance i s
calculated by dividi ng the di ff erence i n vol ume by the dif f erence i n pressure at t wo
poi nts duri ng the vent i l atory cycl e. This i s not a t rue measure of total compli ance,
because t he ai rway pressure incl udes t he pressure needed t o overcome resi stance
(3).
St atic compli ance is calcul ated by usi ng the end-inspi ratory occlusi on pressure
(4,5) (Fi g. 23.22). Condi t ions of zero gas f low are achi eved by empl oying an
i nspi ratory hold or occl udi ng t he expi ratory port l ong enough to al l ow ai rway
pressure to reach a constant val ue. Thi s pressure, commonl y termed pl ateau
pressure, represents the elasti c recoi l of the t otal respi ratory system at end-
i nf l at i on vol ume.
St atic Compl i ance = Ti dal vol ume/Pl ateau pressure - Posi t i ve end-expi ratory
pressure (PEEP)
I n adul ts, normal tot al st atic compl i ance is 35 to 100 mL/cm H
2
O. I n chi l dren,
normal stat i c compl i ance i s great er than 15 mL/cm H
2
O (6).
Total compl i ance ref l ects the el ast ic propert i es of the lungs, thorax, abdomen, and
t he breathi ng system. Usi ng muscl e rel axant s wi l l i ncrease chest wal l compl i ance
but wi l l not af fect l ung compl i ance, so i n paral yzed pati ents, changes in compl i ance
ref l ect mai nl y al t erati ons i n l ung compl i ance.
Resistance
When gas f l ows through a tube, energy i s l ost . Thi s is ref lected by a decrease i n
pressure. The pressure drop can be expressed as the product of resi stance and
f low rate. For a gi ven ti dal volume, a hi gh resistance may be overcome by usi ng a
l ower f l ow f or a l onger ti me or a hi gher dri ving pressure. Duri ng cont rol l ed
venti l ati on, i f there i s an i ncrease i n ai rway resi stance, the pressure needed to
del i ver a gi ven ti dal vol ume wi l l i ncrease. Thi s can usual l y be suppl i ed by the
venti l ator or t he person squeezing the reservoi r bag so that inspi ratory f l ow i s not
af fected. Because exhal at i on is passi ve, expi ratory f l ow depends on the el asti c and
resi st ive f orces of the l ungs and the resi stance in t he expi ratory l i mb of the
breat hi ng system and ai r way device.
Total resist ance, whi ch may dif fer duri ng i nspi rati on and expi rat ion, is determi ned
predomi nantl y by t he resistance of the pat i ent ' s ai rway, t he t racheal tube, and t he
breat hi ng system. Decreased ai rway cal i ber f rom bronchoconst ricti on, secret ions,
t umor, edema, a forei gn body, or ai rway cl osure i s associ ated wi t h i ncreased
resi st ance. Tracheal t ube resi stance depends pri mari l y on i ts i nternal di ameter.
Parti al tube obst ructi on by secreti ons, ki nking, or other probl ems wi l l cause
i ncreased resistance. Breathi ng system resi stance i s af fected by the l ength and
i nternal di amet er of i ts components and i s increased by sharp bends and
const ri ct ions.
Total ai rway resi stance can be est imated by usi ng the dif ference bet ween peak and
pl at eau pressures, whi ch i s normal l y 2 to 5 cm H
2
O. If t here is an i ncrease i n
resi st ance, a higher peak pressure wi l l be necessary t o produce t he same f l ow.
Pl ateau pressure, however, depends onl y on compl i ance and wi l l not be af f ected by
resi st ance. Theref ore, i f the i nspi ratory f l ow and ti dal vol ume remai n constant but
resi st ance i ncreases, there wi l l be a greater dif f erence bet ween the peak and
pl at eau pressures.
Measured Gas Composition
The composi t ion of the gas bei ng measured wi l l af f ect the accuracy of f low-
measuri ng devi ces (7,8). Di f f erences in densi ty and vi scosi t y of the gases can
i nduce an error i n f l ow measurement. The composi ti on of carri er gas has a greater
i mpact on vi scosi t y than vol ati l e anestheti c agents, whereas densi t y is more
i nf l uenced by vol ati l e agent concent rat i ons (9).
For accuracy, t he f l ow-measuri ng device shoul d be associat ed wi th a gas moni t or
t hat can make correcti ons to gas f l ow caused by changes i n gas composi ti on. If a
gas such as xenon t hat i s not measured i s present , f low measurements may be
i naccurate (8).
Respiratory Volume and Flow Measurement
A respi rometer (spi romet er, vent i lat i on or respi ratory met er or moni tor,
venti l ometer, vol ume measuri ng device, f low moni t or, respi ratory fl owmeter) i s a
device that measures the volume of gas passi ng during a peri od of t i me t hrough a
l ocat i on i n a f low pathway (10).
Moni tori ng respi ratory volumes and f l ows can aid i n detect i ng breathing system
obstruct i ons, disconnect i ons, apnea, l eaks, venti lator f ai l ure, and hi gh or l ow
volumes i n spont aneousl y breathing pati ents as wel l as i n those whose venti lati on
i s cont roll ed. Some can detect reversed f low, an indicat i on of an incompetent
uni di rect ional valve or a l eak. A di screpancy between expi red and i nspi red ti dal
volume shoul d suggest a l eak.
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A decrease in t idal volume associated wi th t he tracheal tube mi grati ng i nto a
bronchus may be detected (11). Al though there are other ways of detecti ng t hese
probl ems, such as observi ng chest wal l movements, moni tori ng breath sounds,
capnomet ry, and ai rway pressure moni t ori ng, the use of a vol ume moni t or provi des
addi ti onal protecti on. One study found that f or detecti ng and classi f ying breathi ng
system f aul ts, a vol ume moni tor was bett er t han ai rway pressure or carbon dioxide
moni tori ng (12). In 1999, t he American Soci et y of Anest hesi ol ogi sts (ASA) st rongl y
encouraged qual i tat ive moni tori ng of the vol ume of expi red gas. The anesthesia
workstat ion standard requi res a device to moni t or t he pati ent' s exhal ed ti dal or
mi nute vol ume or both (13).
Respi rat ory vol ume moni tori ng may fail t o det ect some probl ems. Wi th ai rway
occl usi on, t here may be enough f l ow duri ng expi rati on resul t ing f rom compressi on
of gas wi t hi n the breathi ng syst em duri ng i nspi rati on to prevent t he respi romet er
al arm f rom bei ng activated. If the sensor i s at tached t o the pati ent ' s tracheal t ube
or supragl ot ti c ai rway devi ce, a di sconnect ion between the sensor and the
breat hi ng system wi l l not be detected i f t he pati ent i s spontaneousl y breathi ng. If
t he sensor i s i n the exhalati on si de of t he breathi ng system, t he di sconnecti on wi l l
be detected. It is possi bl e to have fai rl y normal f l ow wi t h esophageal i ntubat ion.
A hi gh-vol ume al arm may be usef ul to detect unant ici pated i ncreases in t i dal
volume (14). Thi s may be due t o improper venti lator set ti ngs or i ncreased gas f l ow
i nto t he breathi ng system duri ng inspi rat i on, resul t ing f rom a hol e i n the vent il ator
bel l ows, an increased i nspi rat ory:expi rat ory (I :E) rat i o, or f rom the f l owmet ers (i f
t here i s no f resh gas fl ow compensati on or decoupl i ng). Duri ng pressure control
venti l ati on, a decrease i n compl i ance wi l l resul t i n an i ncreased t idal volume.
Ol der respi rometers were st ri ctl y mechanical devices. Newer respi romet ers convert
f low i nt o an electroni c si gnal that i s processed and di spl ayed. El ectroni c processi ng
enhances al arm capabi l i t y. Al arm l i mi ts shoul d be set as cl ose as possi bl e to t he
di spl ayed ti dal or minut e vol ume wi t hout produci ng an unacceptabl e i ncidence of
f alse-posi t ive alarms (15).
Equipment
Venti lator Bellows Scale
Venti lators that are used i n anesthesi a are di scussed in Chapter 12. I f the
venti l ator has a bel l ows, there i s usual l y a scal e on the bel lows housi ng. Thi s scal e
can provide a rough esti mate of t i dal vol ume deli vered i nto t he breat hi ng system
but is not an accurate esti mate of the vol ume del ivered to the pati ent because of
wasted vent il ati on secondary to gas compressi on and distensi on of components of
t he breathi ng system. I f the f resh gas f l ow adds to t he t idal volume duri ng
i nspi rati on (see Chapter 12), this added volume wi l l not be represented on thi s
scal e.

View Figure

Figure 23.2 Wright respirometers. A: This small instrument
can be handheld or inserted into the breathing system. It has
two dials: a large peripheral one and a smaller one on the
upper part of the main dial. The small dial indicates
volumes up to 1 L and the large dial up to 100 L. Note the
reset button on the side. B: This version has three dials. The
top small dial reads up to 1 L, the large dial indicates
volumes up to 100 L, and the bottom small dial reads up to
10,000 L. Note the on-off control and the directional flow
arrow. (Courtesy of Ferraris Medical, Inc.)

Wright Respirometers
Description
Typical Wri ght respi rometers are shown i n Fi gure 23.2. They are suppli ed wi th
adapt ors to faci l i tat e connecti on to a mask, ai rway devi ce, or breathi ng system.
There i s an ON-OFF control i n the form of a sli di ng stud and a spri ng-loaded reset
but ton to set the hands of the scal es t o zero.
An i nfant versi on t hat can measure vol umes down to 15 mL i s avai l abl e (Fi g. 23.3).
I ts dead space is 15 mL. An electroni c versi on i s also avai l abl e (15).
The i nt ernal const ructi on i s shown i n Fi gure 23.4. Gas enteri ng t hrough t he outer
casi ng is di rected through a seri es of tangent i al sl ots encl osed in a cyli ndri cal
housi ng and st ri kes a vane, causi ng i t to rotat e. The vane i s connected by a
mechani cal gear system to t he hands on the di al so that a readi ng corresponding to
t he vol ume of gas passing t hrough t he device i s regi stered.
Evaluation
Most studi es have f ound that the Wri ght respi rometer over-reads at hi gh fl ows and
under-reads at low f l ows (16, 17,18). Pulsati l e f l ows can cause addi t i onal over-
readi ng. It wi l l gi ve sl i ghtl y hi gher readi ngs wi th mi xtures of ni trous oxide and
oxygen than f or ai r and wi l l sl i ghtl y over-read in t he presence of xenon (8).
P. 733

View Figure

Figure 23.3 Infant version of Wright respirometer. The
outer scale goes up to 500 mL, and the inner scale goes up
to 5 L. (Courtesy of Ferraris Medical, Inc.)

Advantages of the Wri ght respi rometer incl ude i ts smal l si ze and li ght wei ght . It s
l ow dead space makes i t sui tabl e f or use bet ween the pati ent and t he breathing
system.
The mai n di sadvantage i s that i t has no al arms. I t i s somewhat di ff i cul t to read and
does not give respi rat ory rate. A cl ock i s necessary to determi ne mi nute volume. It
does not read bi di recti onal f low. Mai ntenance can be expensi ve. Many i nst ruments
t hat are in use are i naccurate because of poor mechani cal condi ti on. I ts port abi l i t y
can resul t i n i naccuracy due t o pocket di rt and a hi gh i nci dence of damage f rom
bei ng dropped. Guards that are desi gned t o reduce damage f rom physical abuse
are avai l abl e. I t needs to be cl eaned and disi nf ected between pati ents.
Spiromed
Description
The Spi romed i s an elect ronic respi rometer that i s desi gned for use wi th North
American Drager breat hi ng systems (19,20). As gas f l ows t hrough the moni tor, i t
f orces a pai r of rotors t o counter-rot at e (Fi g. 23.5). At tached t o the axl e of one of
t he rotors is a f our-pronged armature wi t h a smal l magnet at t he ti p of each prong.
As exhal ed gas f l ows through t he sensor, t he rot or and armature spi n in unison.
Located at approxi matel y the 12 and 7 o' cl ock posi ti ons are two t ransi stors that
t urn ON in the presence of a magneti c f i el d. As t he armat ure that carri es the
magnets rot ates, t he transistors are turned ON and OFF. These pai red pul ses are
t ransmi t t ed through the sensor cabl e to the i nterf ace panel and then t o the
processor.

View Figure

Figure 23.4 Internal construction of Wright respirometer.
Gas entering the casing is directed through a series of
tangential slots and strikes the vane in the center, causing it
to rotate.

View Figure

Figure 23.5 Spiromed. (See text for details.)

The number of pai red pulses i s rel at ed to t he vol ume of gas that passes through
t he sensor over t ime. The total number of pul se pai rs counted duri ng each
exhal ati on determi nes t he ti dal vol ume. The speed at whi ch the exhal ed gas f l ows
t hrough the sensor determines the durati on of each pul se pai r. Rapi d gas f l ow
causes t he rotors and armat ure to spi n qui ckl y, and short er pul ses are produced as
t he transist ors rapidl y cycl e. Wi t h sl ower gas f l ow, l onger pulses are produced. The
processor anal yzes the pulse lengths and di spl ays the i nf ormat i on as the exhal ed
waveform.
Si xt y seconds of cont inuous data i s requi red f or t he ini t ial di spl ay of t he respi ratory
rate, and t he di spl ayed reading i s recal cul ated af ter each exhal ati on. For an
exhal ati on t o be counted as a val i d breath, t he processor must count at l east 80
mL. Al l exhal ed gas vol umes, regardl ess of si ze, are counted and i ncl uded i n
calculati ng the mi nute volume. The sensor i n the breathing system is shown i n
Fi gure 23. 6.
The Spi romed sensor recogni zes the di recti on of gas fl ow by moni t ori ng t he phase
rel ati onshi p between the pul ses i n each pulse pai r. When t he gas f lows f orward,
t he pul se f rom one t ransi stor leads the pul se f rom the other transducer because of
t he armature' s rotat ional di rect i on. I f gas f lows i n t he wrong di recti on, t he order
P. 734

of t he pulses is reversed and the processor recogni zes thi s as reverse f low. If t wo
consecutive pulse pai rs are in reverse order, a reverse f l ow al arm is generated.

View Figure

Figure 23.6 Spiromed in place in breathing system.

Evaluation
Thi s i nst rument i s programmed to measure t i dal volumes equal to or greater than
150 mL. If t he t idal vol ume i s l ess than 150 mL, the i nst rument wi l l automati call y
add t wo or more consecut i ve ti dal vol umes and reduce the recorded f requency
accordi ngl y. The mi nute-vol ume di spl ay remai ns correct .
The accuracy of ti dal vol ume measurement i s report ed as 0.04 L, minute volume
as 10% of readi ng or 0. 1 L, and respi ratory rat e as 8% of readi ng or 1
breat h/minute.
D-Lite Gas Sampler and Flow Sensor
Description
The f low sensor (Fi g. 23. 7) f or this devi ce is a modi f ied Flei sch pneumotach wi t h a
t wo-sided Pi tot t ube (21,22, 23,24). The Fl ei sch pneumotach measures f low by
measuri ng the pressure di ff erence across a f l ow resi stor (capi l l ary tube) i n a tube.
The Pi t ot tube uses two sensi ng tubes to make a dif ferenti al pressure
measurement . One tube faces t he di recti on of f l ow (total pressure), and the other
f aces t he opposi te di rect ion t o measure the stati c pressure. The di f f erence i n
pressure between the tot al pressure and stati c pressure i s the dynami c pressure,
whi ch i s proporti onal to t he square of gas f l ow.
The sensor body (Fi g. 23.8) consi sts of a strai ght t ube wi th a combi ned 15-mm
f emal e/22-mm mal e connector on t he pat ient end and a 15-mm mal e connector on
t he machi ne end. Two smal l hol l ow pressure t ubes perf orate t he si de of t he t ube
and extend into the lumen. Each makes a 90-degree turn i nside t he l umen so t hat
t he end of one tube f aces the breathi ng syst em and the other end f aces the pat i ent .
A gas sampl i ng port i s al so present. A doubl e-l umen t ube conducts t he f l ow si gnal
as a pressure di f ference to the pressure sensor i nsi de t he moni tor.
The sensor is pl aced bet ween the breat hi ng system and t he pat ient. A f il t er or heat
and moi st ure exchanger may be pl aced on ei ther side of the sensor. If pl aced
bet ween t he pati ent and the sensor, mucus and humidi t y wi l l be prevented f rom
entering the gas sampl i ng tube. If the sensor i s placed bet ween t he pati ent and the
heat and moi st ure exchanger, a hi gher compl i ance wi l l be observed than if i t i s
pl aced bet ween the heat and moi sture exchanger and the Y-pi ece (25).

View Figure

Figure 23.7 D-Lite flow sensor and gas sampler. The
patient end has a 15-mm internal and 22-mm outside
diameter connector to fit a mask or tracheal tube connector.
The other end has a 15-mm outside diameter connector.
Because the pressure tubes point in opposite directions, gas
flows can be measured during both inspiration and
exhalation. Note that one pressure tube is larger than the
other to avoid misconnection of the tubings. There is a gas
sampling port on the opposite site of the sensor.

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View Figure

Figure 23.8 Sensor for D-Lite flow sensor and gas sampler
A: The gas sample port is at the top. Note that the pressure
line attachments utilize male and female connectors. B:
Attachment for pressure tubings.

During i nspi rat i on, gas moves f rom t he breathing syst em toward t he pati ent. The
pressure i n the hol l ow t ube faci ng the breathi ng system and the pressure i n the
t ube that f aces away f rom the di rect ion of gas f low are measured. Si nce the
pressure tubi ngs f ace i n opposi te di recti ons, si mi l ar measurements can be made
duri ng exhalati on, when the gas fl ow i s reversed.
I n t he moni tor (Fi g. 23.9), concent rati ons of carbon di oxi de, oxygen, and anestheti c
agents are determined. The moni tor uti l i zes the gas composi ti on data to
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compensate f or changes due to densi ty and vi scosi t y (7). A correct ion f actor must
be appl i ed i f hel i um i s i n the respi ratory mixture (26). From t he derived f l ows (f l ow
rate, peak f l ow) and measured pressures (end-expi ratory, pl at eau, mi ni mum, and
maxi mum), the i nspi rat ory and expi ratory t i dal and mi nute vol umes, compli ance,
and resi st ance are calculated and di spl ayed, and f low-volume and pressure-vol ume
l oops are di spl ayed. I nspi red and expi red gas concent rat i ons are also displ ayed.

View Figure

Figure 23.9 The monitor utilizes the gas composition data
to compensate for changes due to density and viscosity.
From the derived flows and measured pressures, the
inspiratory and expiratory tidal and minute volumes,
compliance, and resistance are calculated and displayed,
and flow-volume and pressure-volume loops are displayed.
Inspired and expired gas concentrations are also displayed.

Al arms i ncl ude a high PEEP al arm wi t h a defaul t val ue of 10 cm H
2
O. High pressure
and l ow i nspi ratory pressure al arms have def aul t set ti ngs of 40 and 0 cm H
2
O.
There are hi gh and low expi ratory mi nute volume alarms as wel l as messages for
l eak, disconnect i on, and obst ructi on.
Calibration
The sensor needs to be cali brated at l east every 6 months (27). One i ndi cati on that
cali brati on needs t o be perf ormed is an open or overshoot pressure- and fl ow-
volume l oop (Fi gs. 23.61 and 23.62). The operati on manual shoul d be consul ted f or
t he compl ete procedure. It shoul d be performed wi th t he equipment i n the
confi gurati on that wi l l be used wi th t he next pati ent. Accessories, such as heat and
moi st ure exchangers, pl aced proxi mal t o the sensor wi l l not af fect cal i brati on.
However, if the cli ni ci an wi shes t o place an accessory on t he di stal end of the
sensor, t hen the uni t should be cal ibrated wi th this i n pl ace. A di f f erent si ze of
t racheal tube or the omission of the connector could aff ect t he cali brati on value and
resul t i n incorrect vol ume measurements.
Evaluation
The D-Li te i s used t o measure f l ows i n ranges common for adul ts and chi ldren down
t o 3 kg. Resistance to f low i s 0.5 cm H
2
O at 30 L/mi nute. I ts vol ume is 9. 5 mL.
Ti dal vol umes of 150 to 2000 mL and mi nute volumes of 2.5 to 30 L/minute can be
measured. The pedi -l i te sensor can measure t idal vol umes i n the range f rom 15 to
300 mL. The range of measurement for ai rway pressure i s -20 to +80 cm H
2
O. The
range of f l ow rat es i s -100 t o +100 L/mi nut e. I t over-reads when xenon i s used (8).
Regular vi sual i nspecti on and water removal i s requi red f or t roublef ree
perf ormance. I f used for extended periods wi t h heavy humi di f i cat ion, condensed
wat er may occl ude the pressure sensi ng or gas sampl ing t ubes. The pressure and
sampl e l i ne tubi ngs should be on the upper si de of the sensor.
The D-Li te sensor has a si mple and robust const ruct ion, l ight wei ght , l ow dead
space, and no movi ng parts. I t is not posi t i on dependent and al l ows bi di recti onal
gas f l ow measurement. Smal l amounts of mucus and wat er dropl ets do not af f ect
t he measurements. Onl y one adaptor is needed f or respi romet ry and gas sampl i ng.
I t can be used wi t h both ci rcl e and Mapleson breathi ng systems. Another i mportant
advantage i s the abil i ty t o moni tor f l ow-vol ume and pressure-volume l oops.

View Figure

Figure 23.10 Novometrics sidestream sensor.

Novometrics Si destream Sensor
The Novomet ri cs si destream sensor (Fi g. 23.10) combi nes measurement of f low,
pressure, and carbon dioxi de. Fl ow i s determi ned f rom a di ff erent ial pressure
measurement across a f i xed ori f i ce wi th a spl i t obstruct ion t o one si de of the opti cal
wi ndow used for mainstream carbon di oxide measurement. The sensor has a dead
space of l ess than 0.8 mL, making i t usef ul f or the neonate (28).
Heated Wire Anemometer
I n t he heated-wi re anemometer (thermal di ssi pat i on devi ce) (Fi gs. 23. 11, 23.12),
gas f l ows around a thin wi re (usual l y pl at inum or a plat i num al loy) that i s heated to
a constant t emperature (10). Heat is di ssipated when gas f lows past thi s wi re. The
great er t he vol ume of gas f l owi ng past per uni t ti me, t he more heat wi l l be
di ssi pated. The current l evel i s usual l y low so t hat t he outsi de of the sensor does
not become heat ed.

View Figure

Figure 23.11 Heated wire anemometer.

P. 737

View Figure

Figure 23.12 Heated wire anemometer. One wire is for
measuring flow, and one is for reference.

The hot-wi re sensor t ends to be more accurat e at l ow f l ow rat es. Since i t is
i nsensi tive to f l ow di rect i on, t wo heat ed wi res are needed t o determi ne the f l ow
di recti on. The heat di ssi pated by t he second wi re i s determi ned when there i s no
gas f l ow (e. g. , duri ng i nhal ati on i n t he exhal at ion si de of the breathi ng system). I t
under-reads i n the presence of xenon and sl i ghtl y over-reads wi th ni trous oxide (8).
Ultrasonic Fl ow Sensor
An ul trasound sensor (Fi gs. 23. 13, 23.14, 23. 15) measures t he inf l uence of gas
f low on t he transmission ti mes of pulses between t wo crystal s. Sendi ng and
receivi ng t ransducers are used to transmi t si gnal s through t he f low. The si gnal
t ravel s f aster when movi ng wi th t he f l ow st ream rather t han against t he f l ow st ream.
The dif ference bet ween t he two t ransmi ssi on ti mes i s used t o cal cul ate the f l ow
rate.
The f low sensor has no moving parts, i s easy to cl ean, is autocl avabl e, and i ts
accuracy i s independent of gas composi t i on. The f l ow measurement range is 0 t o
120 L/mi nute. The accuracy i s speci f i ed as 10% or 15 mL, whi chever i s greater.
Resistance is l ess t han 2 cm H
2
O at a f low of 60 L/mi nut e.
Vari abl e Orifi ce Flow Sensor
The vari abl e orif ice f l ow sensor i s used wi t h t he Ohmeda 7900 seri es venti lators
(Chapter 12) and t he ci rcl e system. Sensors at both connect ions to t he carbon
di oxi de absorber are used to measure i nspirat ory and expi ratory f l ows. These
sensors can be used to generat e pressure- and f l ow-vol ume loops. The 7900
venti l ator ut i l i zes the inf ormat ion f rom these sensors t o al l ow i t to del i ver accurate
t i dal vol umes.
Construction
Each sensor (Fi gs. 23.16, 23.17) uses the pri ncipl e of pressure drop across an
ori f i ce. A pl ast i c fl ap that opens wi th i ncreasi ng f lows is pl aced across the di recti on
of gas f l ow. Two sensors and a t ransducer
P. 738

i nsi de the anesthesi a machi ne measure pressure proxi mal and di stal to the f lap.
Vol ume i s cal cul ated f rom these f l ows. The sensor on the i nspi ratory si de i s
connected t o a pressure sensor so that breathi ng system pressure is measured.
The i nf ormati on i s used by the venti lator to compensate f or changes i n f resh gas
f low.

View Figure

Figure 23.13 Ultrasonic flow sensor in breathing system.

View Figure

Figure 23.14 Inside of ultrasonic flow sensor.

Use
Bef ore use, t he t ubes shoul d be checked t o make cert ai n t hat they are cl ear. The
pressure l i nes shoul d point up, and there shoul d be no ki nks, cracks, or ot her
probl ems. The use of f i l ters is recommended t o protect the sensors f rom
contaminati on. Cali brat ion by usi ng a menu on the vent il ator i s recommended on a
weekl y basi s.

View Figure

Figure 23.15 Diagram of ultrasonic flow sensor.

P. 739

View Figure

Figure 23.16 Variable orifice sensor. Gas flow causes the
Milar flap to bend. There is a pressure drop across the flap.
A transducer inside the ventilator converts the pressure drop
into a flow.

Accuracy
The sensor can measure f l ows f rom 1 t o 120 L/minut e. There are no respi ratory
rate l imi ts. The i nst rument wi l l read hi gh wi t h xenon and ni trous oxi de (8).
Si nce both i nspi red and exhal ed vol umes are measured, the vent i l ator can make
adj ustments so that changes i n f resh gas f low do not af fect t he del ivered vol umes.
Si nce t he sensors are l ocated at the absorber, they cannot compensat e f or gas
compressi on or expansion i n the breathing system. Thi s i s a smal l error unless very
compl i ant breathi ng tubes are used or t he breathing syst em contai ns a l arge
volume of gas.
Evaluation
The mai n advantage of thi s device i s that i t al lows the venti l at or t o automati cal l y
compensate f or changes in f resh gas f l ow. Di sadvantages i ncl ude t he need f or t wo
sensors and f il ters. A break i n one of the pressure l i nes can cause a l eak i n the
breat hi ng system
P. 740

(29). The sensor i tsel f may be t he source of a l eak (30,31, 32, 33). The sensors are
sensi ti ve to humi di t y (34,35).

View Figure

Figure 23.17 A: Variable orifice sensor. Tubings are
attached on either side of the flap. B: Tubings from the
sensors attached to the anesthesia machine. It is important
that they are attached to the proper connection.

Fixed Orifi ce Fl ow Sensor
Thi s device consists of a rest ri ct or and two pressure sensors, one on ei ther si de of
t he restrictor. A zeroi ng val ve compensates f or pressure sensor dri f t .
Respirometer Position in the Breathing System
Fi gure 23. 18 shows possible l ocat i ons f or a respi rometer i n the ci rcl e system. From
t he standpoint of accuracy, the most desi rabl e l ocat i on is between the breathi ng
system and the pati ent (posi t i on C). I n this l ocati on, readings are not af fected by
breat hi ng system l eaks, expansion of breathing syst em components, or gas
compressi on. Both i nspi red and expi red volumes can be measured. Pl aci ng the
sensor at this si t e wi l l i ncrease t he dead space, and water condensati on may be a
probl em. This posi ti on may resul t i n i ncreased l ikeli hood of damage, disconnect ion,
or t racheal tube ki nki ng.
A di sadvantage of posi ti on C is t hat i f a di sconnecti on occurs bet ween t he sensor
and the breat hi ng system duri ng spontaneous venti l at ion, the spi rometry
measurements wi l l not be af fected. I f the sensor i s l ocated at posi t ion B, the
di sconnecti on wi l l be detect ed by t he change in vol ume.
A common pract i ce is t o locate the respi romet er i n t he exhal ati on l imb upst ream or
downst ream of the uni di rect ional val ve (posi ti ons A and B). An advantage of these
posi t i ons i s that if the respi rometer can sense reverse f low, a mal f uncti oni ng
uni di rect ional valve can be detected. If a disconnecti on that prevents exhal ed
gases f rom passi ng down t he exhal ati on tubi ng occurs, the respi rometer wi l l not
sense a gas f l ow, and an apnea message and alarm wi l l be acti vat ed. A
respi rometer i n t hi s locat ion wi l l usuall y read accuratel y duri ng spontaneous
respi rati on, but duri ng control led respi rat ion, i t wi l l usual l y give erroneousl y hi gh
readi ngs
P. 741

(36,37). Thi s is due to expansi on of components of t he breat hi ng system and gas
compressi on. If a venti l ator wi t h a hanging bel l ows i s used, a respi rometer i n this
posi t i on may st il l i ndi cat e f l ow when a di sconnecti on occurs (38).

View Figure

Figure 23.18 Possible sites for a respirometer in the circle
system. (See text for details.) PEEP, positive end-expiratory
pressure; APL, adjustable pressure limiting.

I f the respi romet er i s located downstream of t he absorber (posi ti on E), t he vol ume
of gas measured wi l l be decreased by the amount of carbon di oxi de absorbed in t he
absorber.
Another possi ble l ocati on for the respi rometer i s on the i nspi ratory side of the
system (posi t ion D). I n thi s l ocat i on, the respi rometer wi l l di splay erroneousl y hi gh
readi ngs, as gas t hat does not inf l ate the pati ent ' s l ungs wi l l al so pass through i t .
During cont roll ed venti l ati on, a disconnect i on may not be detect ed.
I t i s common to l ocate pressure-f low sensors at both posi ti ons B and D. This al l ows
both the inspi rat ory and exhal ati on volumes and pressures to be measured. Thi s
provi des t he i nformat i on to produce a f l ow-vol ume or pressure-volume l oop.
Sensors in both these posi ti ons are used wi t h t he Dat ex-Ohmeda 7900 venti l ator to
compensate f or changes i n t idal vol ume due t o f resh gas f l ow or l eaks.
When one of these devices i s used i n a Mapleson system wi th an adul t pat i ent , i t
shoul d be pl aced between t he pati ent connect ion port and the pati ent. I n smal ler
pati ents, i t shoul d be pl aced i n the expi ratory l i mb to avoid an i ncrease in dead
space (11,15).
Airway Pressure Monitoring
Ai rway pressure moni tors (vent i l at or or respi rat ory moni tors or al arms; pressure
al arms; pressure al arm systems; anesthesi a, pat i ent , or breathi ng ci rcui t moni tors;
venti l ator moni tori ng al arms; breathi ng gas i nterrupt ion moni tors; disconnect
moni tors; breathi ng pressure moni tors) are used to warn of hi gh- or l ow-pressure
condi ti ons i n the breathi ng syst em (39, 40).
Hi gh- or low-pressure condi ti ons i n the breathing syst em have been a major cause
of anest hesi a mort al i t y and morbidi t y. A devi ce that responds to pressure changes
wi thi n t he breathing syst em and provi des warni ng of a probl em is strongl y
recommended. Other parameters such as exhal ed carbon di oxide and exhaled
volumes may remai n rel ati vel y normal i n the presence of dangerousl y abnormal
ai rway pressures.
Conti nuous ai rway pressure moni tori ng i s now t he norm i n both the operati ng room
and i n cri t ical care areas. It i s a si mpl e and noni nvasive techni que t hat hel ps i n
assessing t he pati ent ' s mechanical and spont aneous venti l ati on and determi ni ng
t he presence of PEEP.
P. 742

View Figure

Figure 23.19 Virtual pressure gauge on anesthesia machine
display. This can be displayed on demand.

Equipment
An ai rway pressure moni tor may be f reestandi ng or i ncorporated i nto a venti l ator or
an anest hesi a machi ne. Most of t hese devi ces are inexpensi ve, robust , easy to use,
and rel iabl e. They may be powered ei ther f rom the main el ect ri cal system wi th
bat tery backup or by a bat tery wi th battery t est capabi li ty.
Most new anesthesi a machi nes have a bui l t-i n data screen where i nf ormati on
i ncl udi ng ai rway pressure is avai labl e. Usual l y, t here wi l l be an ai rway pressure
versus ti me wavef orm di spl ayed on this screen. A vi rt ual el ect ronic pressure gauge
may be di splayed on the moni tor screen (Fig. 23.19). Many machines i n use are
st i l l equi pped wi t h a mechani cal pressure gauge on the absorber. This does not
al l ow el ectroni c recordi ng or t he data to be i ntegrated wi t h other parameters t o
al l ow compl iance calculati ons. Al arms were not associated wi t h t hese manomet ers,
so t hey had to be repeatedl y scanned by t he anesthesi a provi der.
Alarms
Most pressure al arms have an audio pause (del ay, mute, si l encing) control that wi l l
del ay t he audible si gnal f or some or al l f uncti ons. Thi s pause shoul d not prevent
t he vi sual si gnal f rom f uncti oni ng. Some uni ts' audible al arms can be completel y
t urned OFF (41). Ot her f eat ures on some devi ces i ncl ude automati c act ivati on when
a pressure i s detected, t he abi l i t y to detect i mpendi ng batt ery f ai l ure, and
protect ion f rom acci dental i nacti vati on or power f ai l ure (42,43). Some ai rway
pressure moni tors have t he abi l i t y to di spl ay pressure wavef orms.
Low Peak I nspiratory Pressure
A low peak i nspi ratory pressure (mi ni mum ai rway pressure, l ow ai r way pressure,
venti l ati on f ai l ure, apnea, cycl i ng, pressure fai l ure, di sconnect, vent i lat or
di sconnect, mi ni mum venti latory, venti l at ion pressure, t hreshol d pressure, low-
pressure, peak ai rway, f ai l -t o-cycl e, l ow pressure, low ci rcui t pressure) al arm is
acti vated i f the pressure detect ed does not exceed a preset minimum wi thi n a f i xed
t i me.
Basic moni toring standards adopted by the ASA and t he American Associ ati on of
Nurse Anestheti sts (AANA) st ate t hat when venti l ati on i s cont rol l ed by a mechani cal
venti l ator, t here shal l be a means of detecti ng di sconnecti on of breathing system
components i n cont i nuous use. Such an al arm has been recommended by other
responsi bl e bodi es around t he worl d (44). The l ow peak i nspi ratory pressure al arm
i s one of the means to fulf i l l thi s requi rement. However, t he pressure moni tor i s not
f ool proof . Under certai n ci rcumstances, i t may f ai l to detect anestheti c ci rcui t
di sconnecti ons. Pressure moni t ori ng wi l l fai l t o detect a di sconnect ion that occurs
duri ng spontaneous vent il at i on (45).
The ai rway pressure must exceed a threshol d val ue (l i mi t ) to prevent an al arm. If
t his l i mi t i s not reached over a period of ti me, usual l y around 15 seconds, the al arm
i s act ivated. The threshold needs to be set at a val ue sl ightl y bel ow the peak
ai rway pressure. This value varies, dependi ng on t he cl i nical si tuat ion. The l imi t
may be set manual l y or automati cal l y around a val ue sl i ght l y l ower t han t he peak
pressure determi ned by several successi ve breat hs. When the peak ai rway
pressure becomes hi gher or l ower, t he threshol d may be aut omat ical l y al tered or
t here may be a means to move the threshold cl oser to t he new peak pressure (Fi g.
23.20). On some machi nes, there wi l l be a visual i nf ormati onal si gnal that the l i mi t
i s set too l ow.
The l ow peak pressure alarm is enabl ed when the venti l ator is t urned ON. I t is
i nact i ve when t he venti l ator is not bei ng used.
Condi t i ons t hat can cause a l ow peak pressure al arm incl ude a di sconnecti on or
maj or l eak i n the breathi ng system; an obstruct i on upst ream of the pressure sensor;
i nadequate f resh gas f l ow (di sconnecti on of the f resh gas l ine, an i nternal machine
obstruct i on, or l oss or reducti on of pi peli ne pressure); t he bag/venti l ator sel ector
P. 743

valve i n the bag posi t ion; a leaki ng t racheal tube cuf f ; extubat ion; a faul t y, poorl y
set, or unconnected vent il ator; fai l ure of the gas or power suppl y to the venti lat or; a
mal f unct ioni ng scavengi ng system; i ncreased compl i ance; reduced resi stance; and
a sucti on device mi stakenl y pl aced wi thi n the gas f low pathway (46,47). Low
pressure al arms are of l i tt l e or no use duri ng spontaneous breathing when the
pressure i n the syst em does not ri se and f al l appreciabl y (45).

View Figure

Figure 23.20 The pressure (top waveform) exceeds the
threshold (dotted line) by a small amount. At the bottom is a
touch control marked AUTO PRESSURE THRESHOLD.
If the threshold is too high or too low, it can be altered by
using the control or by touching the threshold on the screen
and moving it to the desired location.

The al arm threshold shoul d be set j ust bel ow the mi ni mum peak pressure expected
duri ng inspi rati on (41,42,48,49). Thi s peak pressure wi l l vary not onl y f rom pati ent
t o pati ent but also duri ng a gi ven case. Of t en, t he threshol d is set lower i n an
at tempt t o prevent f al se-posi tive alarms. If the al arm l i mi t i s set t oo l ow, a f alse
negat ive may occur (50,51,52). I t has been suggested t hat a pressure threshold of
l ess than 8 to 10 cm H
2
O i s unaccept able (53). On most modern deli very systems,
t he ci rcui t pressure wavef orm and the l ow-pressure al arm threshol d can be
di spl ayed, making i t easy for the operator to adjust the threshol d properl y (Fig.
23.2). On some moni tors, an advisory si gnal wi l l be act i vat ed if the threshold i s set
a certain amount below t he peak pressure. Some uni ts automat i cal l y set t he
t hreshol d based on the pressure sensed duri ng previous breaths. There may be a
manual t hreshol d reset cont rol .
Probl ems wi th these moni tors have been reported. A di sconnecti on or leak may not
be detected i f t he al arm i s not swi t ched ON (54) or t he threshol d is set too l ow. A
f alse-negat ive condi ti on may occur i f the end-expi ratory pressure i s above the
t hreshol d pressure. Other condi t i ons that may produce a pressure hi gh enough to
exceed the threshol d when a di sconnecti on occurs i nclude the breat hi ng system
connector' s obst ructi on by a pi l low, sheet, or surgi cal drape; a hi gh-resi stance
component such as a heat and moisture exchanger, capnometer cuvet te, or
humi di f i er; ai r ent rainment i nto the breat hi ng system (especi al l y wi th a venti l ator
bel l ows descendi ng duri ng expi rat i on); parti al ext ubat ion; compressi on of an empty
venti l ator bel l ows; and a Mapleson syst em wi t h a hi gh resi stance (55,56,57, 58,59).
I f a vent i lator t hat uses a ram of oxygen to produce inspi rati on i s used wi th a T-
pi ece system, a di sconnecti on at the common gas out l et may not be detected due
t o t he hi gh resi stance of the f resh gas tubi ng (60). Those devi ces operati ng on
bat teri es wi l l not alarm i f t he bat teri es f ail . I t i s essenti al t hat the alarm be checked
before use by making a di sconnecti on at the pati ent connect or whi l e the venti l ator
i s cycl i ng (Chapter 33) (50). Unf ortunatel y, studi es show that this t est i s not
perf ormed rout i nel y or correct l y (48). It i s i mport ant that another means of
detecti ng a di sconnecti on (such as a capnograph or vol ume or f l ow moni tor) be
used.
Sustai ned Elevated Pressure
A sustai ned (conti nuous, conti nuing) pressure moni tor acti vates an al arm i f the
pressure does not f al l below a cert ain l evel duri ng part of t he respi rat ory cycle.
Most are al ways enabl ed. Some i ncorporat e a val ve that opens to rel i eve the
pressure af t er a certai n t ime.
Several mechani sms can produce a sustai ned elevated pressure: acci dental
acti vat i on of the oxygen fl ush val ve; occl usi on or obst ructi on of the expi rat ory l i mb;
an i mproperl y adjusted adj ustabl e pressure l i mi ti ng (APL) valve; occl usi on of t he
scavengi ng system; a mal f unct i oni ng venti lator; or a mal f uncti oni ng or i ncorrect l y
set PEEP val ve (42,43,55).
High Pressure
A hi gh-pressure al arm i s act ivated i f the pressure exceeds a cert ai n li mi t . On some
devices, t he threshol d
P. 744

i s fi xed (usuall y 50 to 80 cm H
2
O); on others, i t i s adj ustabl e (41). Some
i nst ruments automati cal l y set the al arm threshold at a set amount above the
average peak pressure f or several previous breat hs. Most of t hese alarms are
al ways enabl ed. There should be no delay on the hi gh-pressure alarm. Some
anesthesi a del i very systems are f i tted wi th pressure-l i mi t ing val ves t hat vent gas
f rom the breathing system when a hi gh pressure is detected (41).
Possi bl e causes of hi gh pressure i ncl ude ai r way obstructi on, reduced compl i ance,
i ncreased resistance, oxygen fl ush activat i on during the i nspi ratory phase, a
punctured venti l at or bell ows, occlusion or obstruct ion of the expi ratory l imb of the
breat hi ng system, scavenger mal funct ion, or t he pat ient coughi ng or strai ni ng
(42,61). Even i n the presence of compl ete obst ruct ion, this al arm wi l l not be
acti vated i f the peak i nspi ratory pressure does not reach the set l imi t (49). Hi gh
compl i ance, l ow resistance, l eaks, l ow i nspi ratory fl ow rates, hi gh respi ratory rates,
l ow I: E rat i os, l ow ti dal vol umes, and l ow f resh gas f lows can al l decrease the peak
i nspi ratory pressure so t hat there i s no al arm condi t i on (2, 62). Duri ng pressure
control venti l at ion, the i nspi ratory ai rway pressure i s preset and t hus cannot act as
a warni ng of t racheal tube occl usi on (63).
Subambient Pressure
A subambi ent (subatmospheri c) pressure al arm i s act i vated by a pressure t hat f al ls
bel ow at mospheric pressure by a predetermi ned amount. Subatmospheric pressure
can be generat ed by a pat ient at tempti ng to i nhal e agai nst a coll apsed reservoi r
bag or i ncreased resi stance; a bl ocked inspi rat ory l i mb (duri ng the venti l at or's
expi ratory phase); a mal f unct i oni ng acti ve cl osed scavengi ng system; suct i on
appli ed to a nasogast ri c tube pl aced i n the tracheobronchi al t ree or to t he worki ng
channel of an endoscope passed i nto the ai r way; a si destream gas anal yzer; or the
ref i l l i ng of a hangi ng bel l ows venti l ator bel lows (14,42,49,64,65,66).
Monitoring Site
The l ocati on where pressure i s sensed wi l l af f ect i ts usef ul ness. Fi gure 23.21
shows possi ble si tes. Ideall y, t he si te shoul d be cl ose to the pati ent ' s ai rway
(posi ti on C). Many di sposable breat hi ng systems have a smal l port at the Y-pi ece
t hat can serve as the connect ion si te for tubing that transmi ts the pressure t o a
moni tori ng devi ce (57). Pressures duri ng both i nspi rat ion and exhalati on can be
measured at this si t e. The D-Li te and Novometrics sensors di scussed earli er i n this
chapter
P. 745

are placed at t hi s si te. Pressure- and f l ow-vol ume loops can also be generated f rom
pressures sensed at t hi s si te. Whi l e placement bet ween the pat ient and the
breat hi ng system i s best f rom t hi s standpoint, i n practice i t may present probl ems
wi th dead space, di sconnect ions, t racheal tube ki nki ng, and wat er bui l dup i n the
pi l ot l i ne. The l ines must be connected for every case.

View Figure

Figure 23.21 Possible sites for monitoring airway pressure
in the circle system. (See text for details.) PEEP, positive
end-expiratory pressure; APL, adjustable pressure limiting.

The more di stant t he measurement si te i s f rom the pati ent, the l ess useful i t is as
an esti mat e of ai rway pressure (2, 67). Breat hi ng system resi stance and
compl i ance, l eaks, obstructi ons, and other mechanical f act ors may cause t he
measured pressure to be qui te di ff erent f rom the pressure in t he pati ent 's ai rway
(56).
Frequentl y, the moni tori ng si te is i n the breat hi ng system (posi t ions A, B, and D).
An occlusi on i n the breathing syst em wi l l cause a l ow-pressure state di stal t o the
obstruct i on and a hi gh-pressure stat e proximal to i t, so certai n types of probl ems
may be mi ssed (57). I f PEEP is used, i t wi l l not be i ndicated on a pressure moni tor
l ocated at posi ti on B. Posi ti ons A and D are f requentl y used to moni tor pressure
duri ng inspi rati on and exhal at ion. These locat ions may be used to provi de
pressures for pressure-vol ume loops.
I n t he past, the sensor was someti mes located i n the venti l ator (posi ti on E). Thi s is
unsatisf actory because under cert ai n ci rcumst ances, suff icient back pressure to
i nhi bi t the mi ni mum pressure al arm may be generated at the bel l ows even when
t here i s a di sconnecti on (55,56). Placing t he sensi ng poi nt i n the vent i l ator may
al so resul t i n fai l ure to det ect an i ncorrect l y set bag/vent i l ator sel ector valve.
Spirometry Loops
A loop is a graphi c representat i on of the dynamic rel ati onshi p bet ween two
vari abl es (pressure and volume or f l ow and vol ume) during both i nspi rati on and
exhal ati on (6,23,68). The f low, vol ume, and pressure curves i l lustrated i n Fi gure
23.1 are t he bases of spi romet ry l oops.
Pressure- and f l ow-vol ume l oops are avai l abl e on cert ai n physi ol ogi c moni tors as
an opti on. Later-generat i on anesthesi a machi nes and most physi ol ogi c moni tors
now of f er these l oops, usual l y as an opti on. The authors bel i eve that t he
i nformati on provi ded j ust if i es the extra cost.
Illustrative Loops
The Pressure-volume Loop
The pressure-vol ume (compli ance) l oop shows vol ume on the verti cal axi s and
ai rway pressure on the hori zontal axi s (Fig. 23.22). Wi th control led vent i l at ion, t he
pressure i n the breathi ng system i ncreases duri ng inspi rat i on. At the same ti me, t he
i nspi red vol ume of gas increases. The t idal vol ume i s the point on the verti cal axi s
t hat corresponds t o the hi ghest point on the l oop. The peak pressure i s the hi ghest
value on t he hori zont al axi s. The shape of the i nspi rat ory phase i s det ermi ned by
t he type of respi rati on bei ng moni t ored.

View Figure

Figure 23.22 Pressure-volume loop. The pressure-volume
relationship reflects pulmonary and tracheal tube
mechanics. During controlled ventilation, a line drawn from
the zero point through the point of end inspiration represents
the compliance, which is determined by dividing the tidal
volume by the pressure at end inspiration. With good
compliance, that line forms an angle of 45 degrees or less
with the volume scale. A loop that becomes more horizontal
indicates a decrease in compliance.

A l i ne drawn f rom the zero point through the point of end i nspi rat ion duri ng
control led vent il ati on (Fi g. 23.22) represents the compl i ance. Wi th good
compl i ance, that l i ne forms an angl e of 45 degrees or l ess wi t h the volume scal e. A
l oop that becomes more hori zontal i ndi cates a decrease i n compl i ance.
The port i on of the loop represent ing exhal ati on starts at t he poi nt of highest vol ume
and moves downward t oward zero. The area i nsi de t he loop is rel ated to the work of
breat hi ng (1,69).
The Flow-volume Loop
The f low-v ol ume (resi stance) loop (Fi g. 23.23) has vol ume on the hori zontal axi s
and f l ow on t he vert ical axis. The zero poi nt f or vol ume i s to t he right on the
hori zont al axi s, correspondi ng to f uncti onal resi dual capaci t y. Duri ng i nspi rati on,
f low rate i ncreases (pl ot ted downward). The i nspi ratory f l ow drops to zero as
i nspi rati on ends. The ti dal vol ume is reached at the poi nt where f l ow ret urns t o zero
and the l oop crosses the hori zontal axi s. The shape of this part of the l oop depends
on the mechani sm of respi rat i on (e.g. , volume cont rol l ed, pressure cont rol l ed,
manual , or spontaneous).
P. 746

View Figure

Figure 23.23 Flow-volume loops with controlled
ventilation.

Exhal ati on i s represented by the part of t he l oop above the hori zontal axi s. The
shape of t hi s porti on of the l oop is determi ned by the rate of passi ve l ung def l at ion,
whi ch i s in t urn determi ned by el asti c recoi l of the lung and chest wal l and by the
t otal fl ow resi stance of f ered by t he bronchi al t ree, ai rway devi ce tube, expi ratory
l i mb of the breathi ng system, and any addi ti onal equipment. Wi th a normal loop, the
f low rate duri ng exhal ati on i ncreases rapi dly at the begi nni ng, quickl y reaches a
peak, then sl ows and gradual l y ret urns to zero.
Fi gure 23. 24 shows another way of i l l ust rati ng a f l ow-vol ume l oop that i s used by
some manuf act urers. The zero poi nt i s at t he juncti on of the hori zont al wi th t he
vertical axis. Inhal ati on i s above the hori zontal axi s, and exhalat i on is bel ow. Fl ow-
volume l oops i l l ustrat ed i n t hi s chapter empl oy the representati on used by
pul monologi sts. Thi s loop may be presented i n ot her ways, but the basi c loop is t he
same.

View Figure

Figure 23.24 Alternative method of displaying flow-
volume loops. (See text for details.)

Representative Normal Loops
Loops that are i l l ust rat ed i n thi s chapter do not come f rom act ual pati ents but are
st yl i zed to i l lustrat e cert ai n aspects of respi ratory mechani cs. They are based on
actual l oops as much as possi bl e. The reader shoul d not expect t o see an exact
reproducti on of t hese l oops when moni tori ng a pat i ent . Cl i ni cal condi t i ons and
venti l ator f uncti on are rarel y st raightf orward and usual l y incl ude a number of
f act ors. The l oop represents a composi te of mechanical and physiologic f act ors. As
f ami l i ari t y wi t h the l oops i ncreases, the user can progress to the fi ner detai l s of
i nterpretat ion.
Volume-control led Ventilation with No Inspiratory Pause
Pressure-volume Loop
The pressure-vol ume l oop f or vol ume-cont rol l ed venti l ati on wi th no i nspi ratory
pause i s shown i n Fi gure 23.22. It begi ns at zero vol ume and near or at zero
pressure. During i nspi rat ion, bot h pressure and vol ume i ncrease, so the l oop moves
up and to the ri ght . At t he end of i nspi rat ion, both peak pressure and t idal vol ume
are att ai ned. The end of i nspi rat i on represents a fal l i n pressure that occurs bef ore
exhal ati on can begi n. The loop ret urns downward and toward the l ef t t o i ts ori gi nal
starti ng posi t i on.
Flow-volume Loop
The f low-v ol ume l oop seen wi th vol ume-cont rol l ed vent i lati on wi th a constant f low
generator is shown i n Fi gure 23. 23. The fl ow qui ckl y rises to a l evel that is
const ant , produci ng a f l at i nspi ratory porti on. At the end of i nspi rati on, the f l ow
drops rapi dl y to zero. The ti dal vol ume is reached as t he loop crosses t he volume
l i ne.
As exhal ati on begi ns, there is a rapi d ascent t o a peak. Fl ow t hen decreases, and
t he l oop fal l s smoothl y toward zero f l ow and vol ume. The angl e at the top of the
l oop i s narrow.
Control led Venti lation with Positive End-expiratory
Pressure
The addi ti on of PEEP causes the starti ng point of the pressure-vol ume l oop to shif t
t o t he ri ght by t he amount of PEEP t hat i s appl i ed (Fi g. 23.25). PEEP may cause an
i ncrease i n compl i ance and is represented by the l oop becomi ng more vert i cal wi t h
a decrease in peak pressure. If t he l oop tends more to the ri ght , PEEP may not be
benef ici al and may need to be wi thdrawn.
The l oop di splay makes i t easy to detect inadvertent PEEP. Thi s may be due t o the
PEEP valve havi ng been i nadvertentl y t urned ON, a parti al obst ructi on i n t he
breat hi ng system, a malf uncti oni ng exhal ati on unidi recti onal val ve, f ai lure of t he
posi t i ve-pressure rel i ef i n the scavengi ng i nterf ace, or an i ncorrect l y set APL valve.
P. 747

View Figure

Figure 23.25 With PEEP, the loop is shifted to the right.
PEEP, positive end-expiratory pressure.

Flow-volume Loop
The f low-v ol ume l oop wi t h PEEP duri ng cont rol l ed vent i lati on wi th a constant f low
venti l ator is shown i n Figure 23.26. PEEP wi l l decrease the expi ratory dri vi ng
pressure, produci ng l ower f l ows duri ng exhalati on so that the l oop appears f l att er
(4).
Control led Venti lation with an Inspiratory Pause
Fi gure 23. 27 shows the pressure-volume l oop duri ng control led vent i l ati on wi t h an
i nspi ratory pause. Af ter t he peak pressure is reached, the venti lator pauses for a
short t i me wi t h t he l ungs i nf l ated. Duri ng t hi s pause, t he pressure i n the breat hi ng
system drops to a plateau level , usual l y 2 to 5 cm H
2
O l ower t han peak pressure.
Fresh gas enteri ng the breathi ng system f rom t he anesthesi a machine wi t hout f resh
gas decoupl ing (Chapter 12) wi l l i ncrease the i nspi red vol ume. Duri ng exhal at i on,
t he pressure and volume wi l l drop i n the expected manner.
Flow-volume Loop
The f low-v ol ume l oop seen wi th an i nspi ratory pause i s shown i n Figure 23.28.
There i s a drop i n f l ow near the end of i nspi rati on wi th a smal l i ncrease i n t i dal
volume duri ng the pause resul t i ng f rom f resh gas f lowi ng i nto the breathi ng system
i f there i s no f resh gas decoupl ing. Thi s patt ern shoul d not be conf used wi t h a
spontaneous breath duri ng control led vent i lat i on (Fi g. 23.60). The i ncrease i n
volume due to f resh gas f l ow i s strai ght , f rom ri ght t o lef t , and stays near t he zero
f low l i ne. Exhal ati on i s si mi l ar t o t he l oop wi thout an i nspi rat ory pause.

View Figure

Figure 23.26 PEEP produces a decrease in expiratory flow.

P. 748

View Figure

Figure 23.27 During an inspiratory pause, it is common for
the airway pressure to decline 2 to 5 cm H
2
O. The lower
pressure is called the plateau pressure. If the ventilator does
not block fresh gas flow during inspiration (fresh gas
decoupling) there will be an increase in tidal volume during
the inspiratory pause.

Pressure-controll ed Venti lation
Pressure-control led vent il at i on di ff ers f rom volume-cont rol l ed respi rat i on in t hat t he
i nspi ratory f low i s not constant . Pressure-control l ed vent i l ati on is discussed in
Chapter 12.
The pressure-vol ume l oop i s shown i n Fi gure 23.29. The loop is wi der t han that
seen wi t h vol ume-control l ed venti l at ion and start s of f wi th a greater pressure rise
t han vol ume i ncrease. As i nspi rati on proceeds, vol ume ri ses f aster t han wi th
volume-control l ed vent i l at i on.
Flow-volume Loop
The pressure-cont roll ed mode of vent i l at i on has an accel erati ng-decel erati ng
i nspi ratory f low prof i l e in cont rast to the constant i nspi ratory f l ow seen wi th vol ume-
control led vent il ati on (Fi g. 23.30). The exhal ati on part of t he l oop i s si mi l ar t o that
wi th volume-cont rol l ed vent i l ati on.

View Figure

Figure 23.28 The blip near the end of inspiration represents
the increase in tidal volume during the inspiratory pause due
to fresh gas continuing to flow into the breathing system.
This will not be seen if the ventilator has fresh gas
decoupling.

P. 749

View Figure

Figure 23.29 Pressure-volume loop with pressure-
controlled ventilation. Pressure rises rapidly to the set
pressure during inspiration.

Spontaneous Respiration without Positive End-expiratory
Pressure
Wi th spontaneous respi rat ion and no PEEP, the pressure-volume l oop (Fi g. 23.31)
starts out at zero pressure and vol ume. Duri ng inspi rati on ai rway, pressure i s
negat ive, so t he loop moves i n a clockwi se di recti on. At t he end of i nspi rat i on, the
pressure returns to zero. At thi s poi nt , the loop crosses t he t idal vol ume poi nt on
t he ordinate. During exhal at ion, ai rway pressure becomes posi t i ve, and t he l oop
moves to t he ri ght . At t he same t ime, the vol ume drops. At t he end of exhalati on,
t he pressure and volume ret urn to zero. The shape of the l oop i s st il l doubl e
convex, but i ts slope is dif f erent f rom that seen wi t h cont roll ed venti l ati on.
Compl i ance cannot be cal culat ed f rom this l oop because the i nspi ratory pressure i s
negat ive. The area of the l oop represents the work of breathing.
Flow-volume Loop
The f low-v ol ume l oop wi t h spontaneous respi rati on i s shown i n Fi gure 23.32. The
f low rate duri ng i nspi rati on vari es more than wi t h mechanical venti l ati on. Peak f l ow
occurs near t he mi ddl e of inspi rati on. At the end of i nspi rati on, f l ow becomes zero,
and the l oop crosses the hori zontal li ne at a vol ume corresponding to the t i dal
volume. The f low duri ng exhalati on i s simi l ar t o t hat found in other forms of
respi rati on.

View Figure

Figure 23.30 Flow-volume loop with pressure-controlled
ventilation. Flow is rapid at the beginning of inspiration,
then decreases.

P. 750

View Figure

Figure 23.31 With spontaneous ventilation, the shape of the
loop is double convex, but the slope is different from that
seen with controlled ventilation. PEEP, positive end-
expiratory pressure.

Spontaneous Respiration with Positive End-expiratory
Pressure
I f PEEP is appl ied duri ng spontaneous venti l ati on, the pressure-vol ume l oop wi l l
start out at the PEEP val ue and move to the l ef t (Fi g. 23. 33). Inspi rati on cannot
begin unti l the pressure has become negat ive. At t hi s poi nt, the t idal vol ume
i ncreases rapidl y. Duri ng exhal at ion, pressure i ncreases rapidly, and t he loop
moves toward t he ri ght and downward t o the point of ori gin. The l oop has a
rectangular shape. The l arger i nternal area of t he l oop i ndi cates the increased work
of breathi ng.
Flow-volume Loop
The correspondi ng f low-volume l oop duri ng spontaneous respi rati on wi t h PEEP is
shown i n Fi gure 23.34. Both the inspi ratory and exhal ati on port i ons of the l oop are
f lat t ened. The exhal ati on port ion i s more rounded t han when PEEP i s not present .
Thi s conf i gurat ion i s si mi l ar t o the l oop demonstrat ing a f ixed inspi ratory and
expi ratory obst ructi on (Fi g. 23. 52).
Face Mask Positive-pressure Ventilation
The basi c shape of the pressure-vol ume loop is sti l l double convex (Fi g. 23.35).
The i nspi ratory port i on of the l oop is more rounded. If t here is a si gni f icant l eak
around the mask, an open l oop may be seen.
Flow-volume Loop
The f low-v ol ume l oop wi t h mask venti l ati on (Fi g. 23.36) i s more rounded duri ng
both i nspi rati on and exhal at ion t han t hat seen wi th i nt ubat i on. This can vary wi t h
t he way i n which t he anesthesi a provi der squeezes the bag.
Intermittent Mandatory Ventil ation
I ntermi tt ent mandatory vent i lat i on produces a combi nati on of l oops representi ng
both spontaneous and control led breaths.

View Figure

Figure 23.32 With spontaneous ventilation, the flow rate
during inspiration varies more than with mechanical
ventilation. Inspiration and exhalation tend to mirror each
other. Tidal volume during spontaneous ventilation is
usually lower than with controlled ventilation.

P. 751

View Figure

Figure 23.33 With spontaneous ventilation and positive
end-expiratory pressure, the loop is shifted leftward and
becomes rectangular. PEEP, positive end-expiratory
pressure.

The pressure-vol ume l oop (Fi g. 23.37) shows both a spontaneous breath (sol i d l i ne)
and a control l ed breath (dashed l i ne). Most moni tors wi l l di spl ay these l oops
consecutivel y and not on t he same screen as il l ust rated unless one of t he l oops has
been previ ousl y saved.
Flow-volume Loop
The f low-v ol ume l oop (Fi g. 23.38) shows a spontaneous breath (sol i d l i ne) and a
control led breath (dashed li ne). Each has the characteristi cs of the normal loop for
t his t ype of respi rati on.
Patient-triggered Ventilati on
I f the venti l at or i s in a tri ggeri ng mode (pressure support vent il at i on), a
spontaneous breath wi l l be necessary t o ini ti ate a posi t ive-pressure respi rat i on.
The pressure-vol ume l oop wi l l start out negat i vel y, but as the vent i lator i s engaged,
t he l oop becomes rapidl y posi ti ve for
P. 752

t he durati on of inspi rati on (Fi g. 23.39). The exhal ati on port ion of the l oop wi l l be
si mi l ar t o that f ound i n cont rol l ed venti l ati on. The f low-volume l oop associ ated wi th
pressure support vent i l at ion i s shown i n Fi gure 23.40.

View Figure

Figure 23.34 PEEP during spontaneous respiration results
in lower flows during both inspiration and exhalation.

View Figure

Figure 23.35 With mask ventilation, the pressure rises more
slowly during inspiration. During expiration, the absence of
the tracheal tube decreases resistance to flow and volume
and pressure drops rapidly. The shape of the upstroke will
vary.

Spontaneous-assisted Venti lation
I f the spontaneousl y breat hi ng pat i ent i s not produci ng a satisf actory t idal vol ume,
respi rati on i s of ten manual l y assi sted. Fi gure 23.41 shows one of t he conf i gurat i ons
of t he pressure-vol ume l oop t hat may be seen. As the pati ent i ni t i ates the
venti l ati on, there wi l l f i rst be a negati ve pressure. As the bag is squeezed, pressure
and t i dal volume i ncrease.
Loops Representative of Patient Factors
Vari ati ons f rom a normal l oop can be caused by anything that aff ects t he way gas
moves past the sensor during i nspi rat ion or expi rati on. Thi s may be a pat ient
f act or, a ci rcui t vari abl e, or a venti lat or vari abl e.
Changes in Compli ance
A maj or advantage of pressure-vol ume loops i s thei r abil i ty t o det ect changes in
compl i ance. If the lungs or chest wal l become sti ff er, i ncreased pressure wi l l be
necessary to del iver t he same t idal vol ume. Thi s causes the pressure-vol ume loop
t o be
P. 753

di spl aced cl ockwi se (Fi g. 23.42). I f PEEP i s i nt roduced, t here may or may not be an
i ncrease i n compl i ance (Fi g. 23.43). I f PEEP does not i ncrease compl i ance or
makes the si tuat ion worse, this can be determi ned by subsequent l oops.

View Figure

Figure 23.36 Mask ventilation. The inspiratory flow is
more variable when ventilation is manually controlled than
when a ventilator is used. During exhalation, the lower
resistance due to the absence of a tracheal tube results in
higher flow.

View Figure

Figure 23.37 Pressure-volume loop with intermittent
mandatory ventilation.

Flow-volume Loop
Decreases i n compl i ance wi l l aff ect the f l ow-v ol ume loop (Fi g. 23.44). Flow wi l l be
i ncreased during exhal at i on, wi th a hi gher peak and a steeper slope.
Decreases i n compl i ance can resul t f rom i nadequate muscl e rel axati on; ai r
embol i sm; diseases and tumors that i nvade l arge areas of the l ung or al ter i ts
di stensibi l i t y; narcotics; bronchi al i ntubat i on; bronchoconst ri cti on; pneumothorax;
reducti on pneumopl ast y; l ateral decubi t us, l i thotomy, or Trendelenburg posi t ions;
external pressure on the chest or abdomen; abdomi nal retract ors or packi ng;
abdomi nal enlargement ; curvat ure of the spi ne; obesi t y; prone posi ti on;
pressuri zati on i n the peri toneal cavi ty duri ng l aparoscopi c surgery; or adul t
respi ratory di st ress syndrome (ARDS) (6,68, 70,71, 72,73,74, 75,76,77, 78, 79,80).
Decreases i n compl i ance can be found during part i al coronary bypass. The l oop
returns to the prebypass state af ter the bypass is di scont inued. Compl i ance is
l ower i n chi l dren t han i n adul ts (Fi g. 23.45) (80).
Factors that i ncrease compl iance i ncl ude PEEP, emphysema, and resol uti on of the
f act ors that decrease compl iance. Since changes i n compl i ance of t en occur
graduall y, t hey may not be recogni zed unl ess the change i s l arge. It is usef ul ,
t herefore, to st ore a l oop f rom the begi nni ng of a case f or compari son.

View Figure

Figure 23.38 Flow-volume loop with intermittent
mandatory ventilation.

P. 754

View Figure

Figure 23.39 Patient-triggered ventilation. As the patient
takes a spontaneous breath, the loop becomes positive for
the duration of inspiration.

Changes in Resi stance
An i ncrease i n resistance may be caused by t racheal tube obstruct ion (ki nki ng,
di sl odgment , or secreti ons), bronchoconst ri ct i on, ai rway col l apse f rom l oss of
el ast i c recoi l or by obstructi on in a l arge ai rway caused by secreti ons, bl ood,
f oreign body, neopl asm, inf l ammat ion, or usi ng a t racheal tube that i s too small .
Whi le mi ld bronchospasm causes only sl i ght changes in t he f l ow-vol ume l oop, as i t
i ncreases there wi l l be changes i n both t he i nspi ratory and exhal at ion porti ons.
Wi th severe expi rat ory resistance, expi ratory f l ow may st op abruptl y bef ore t he next
mechani cal inf l at ion. The ef f ects of treat ment for bronchospasm can be assessed
by observi ng the l oop af t er t reatment.
During cont roll ed venti l ati on, i ncreased resi stance means that hi gher i nspi ratory
pressures wi l l be requi red to del i ver a gi ven f l ow. Ti dal vol ume may be reduced. As
shown i n Fi gure 23.46 (sol id l i ne), t he pressure-vol ume l oop i s shi f ted t o the ri ght
and downward wi t h a large i nt ernal area. The pressure f al l s rapidl y af t er i nspi rati on
i s compl et e. The l oop may be open i f there i s ai r trappi ng. Wi t h spontaneous
venti l ati on, the i nspi ratory l i mb i s di spl aced l ef t ward (Fi g. 23.47).

View Figure

Figure 23.40 Pressure support ventilation.

P. 755

View Figure

Figure 23.41 Spontaneous-assisted ventilation. As the
patient begins to inspire, a negative pressure is seen. Then
the bag is squeezed and the pressure becomes positive. The
shape of the inspiratory portion will depend on how the bag
is squeezed.

Flow-volume Loop
I f resistance i s i ncreased, the f low-v ol ume l oop wi l l show decreased f l ow
t hroughout exhal ati on (4,21) (Fi g. 23.48). As resi stance i ncreases furt her (Fi g.
23.49), t here wi l l be changes in both t he inspi ratory and exhal ati on port i ons, and
t he ti dal vol ume may be decreased. Wi t h severe expi ratory resi stance, expi ratory
f low may st op abruptl y bef ore t he next mechani cal i nf l ati on.
Chronic Obstructi ve Lung Disease
Emphysema i s characteri zed by a progressi ve l oss of el astic t issue i n the l ung.
These pat i ents have no probl em wi t h infl ating the l ungs but must work t o exhale.
During mechanical venti l at ion, pat i ents wi t h ai rf l ow obstructi on may develop
i nadvert ent PEEP (auto-PEEP, occul t or i ntri nsi c PEEP, dynami c hyperi nf lat i on, ai r
t rapping) i f there i s not enough t i me f or compl ete
P. 756

exhal ati on (81, 82,83,84, 85). The exhal ed volume wi l l be l ess t han the i nspi red
volume.

View Figure

Figure 23.42 Low compliance causes the loop to be moved
closer to the horizontal axis. High compliance causes the
loop to move closer to the vertical axis. The dotted line
shows normal compliance. The solid line shows decreased
compliance.

View Figure

Figure 23.43 The dotted line represents decreased
compliance. With the addition of PEEP, the loop is moved
to the left, and the increased compliance results in a more
normal-looking loop. If the loop does not improve with
PEEP, the PEEP may not be beneficial and may need to be
removed. PEEP, positive end-expiratory pressure.

The pressure-vol ume l oop seen wi th t hi s condi t ion is shown i n Fi gure 23. 50. At the
beginni ng of i nspi rati on, the pressure ri ses sl owl y.
During exhalat i on, the pressure drops wi t h l i tt l e change i n vol ume unt i l the end of
exhal ati on. An open l oop may be seen.
Flow-volume Loop
The correspondi ng f low-volume l oop i s shown i n Fi gure 23. 51. Duri ng expi rati on,
t here i s a severe reducti on i n f l ow. The l oop may be open i f the pati ent does not
have suf f i ci ent ti me to exhal e compl etel y. Interrupt ed expi ratory f low may suggest
t he presence of i ntri nsi c PEEP (auto-PEEP).
Pat i ents wi t h obst ructive ai rway di sease may not compl et e a f ul l exhal ati on prior to
t he start of the next i nhalati on, resul t i ng i n persi stent posi t ive pressure. This wi l l be
i ndi cated by the absence of a peri od of zero f l ow before the next inhal ati on (Fig.
23.63).
Airway Obstruction
Fl ow-vol ume l oops may be helpful in i denti fyi ng ai rway obstructi ons (86,87,88). The
i nspi ratory l imb of the l oop
P. 757

i s usef ul i n di agnosi ng ext rathoracic ai r way obstruct ion, and the expi rat ory l i mb i s
sensi ti ve to i nt rathoracic obst ructi on (87,89). When the cross-secti onal area of the
ai rway i s decreased to a cri ti cal l evel , charact eri stic patterns of f l ow occur wi t h
spontaneous venti lati on. Typi cal l y, the fl ow rate wi l l plateau. The val ue of the fl ow
rate at thi s pl ateau wi l l depend on the cross-secti onal area of the f l ow-l i mi t ing
segment i n the ai rway.

View Figure

Figure 23.44 The dotted line represents decreased
compliance. Flow is greater at the beginning of exhalation
due to the increased pressure.

View Figure

Figure 23.45 Pressure-volume loop in pediatric patient.

Wi th a f i xed i nt rathoracic or t horacic obstruct i on and spontaneous venti l ati on (Fig.
23.52), both the inspi ratory and expi rat ory l i mbs of t he f l ow-vol ume curve are
f lat t ened (86,87, 90).
A variabl e extrat horaci c obstruct i on (Fi g. 23.53) wi l l af f ect i nspi rat i on as the
negat ive pressure causes the obst ructi on to i ncrease. Duri ng exhal ati on, posi t ive
pressure i n the ai rway wi l l keep t he trachea open at the si t e of the l esi on, l eavi ng
t he expi ratory curve unaf f ected (87).
A variabl e i nt rathoracic obst ructi on (Fig. 23. 54) wi l l show a normal i nspi ratory
curve as the negat ive i nt rathoracic pressure wi l l keep t he ai rway open. During
expi rat ion, t he intrathoraci c pressure becomes posi tive
P. 758

and thus decreases t he ai rway di amet er so t hat the expi ratory f l ow i s reduced.

View Figure

Figure 23.46 With an increase in resistance, a higher
pressure is needed to deliver the same volume (solid curve).
Tidal volume may be reduced.

View Figure

Figure 23.47 Spontaneous respiration with increased
resistance. The normal loop is shown with dotted lines.
With increased resistance, greater pressure (more negative
during inspiration, more positive during exhalation) will be
needed to move the same volume of gas.

Restri cti ve Disease
The i ncrease in el asti c recoi l wi t h restri cti ve defects i ncreases the force driving
expi ratory f l ow. Thus, the fl ow-vol ume l oop usual l y shows a hi gh expi ratory f l ow
associ ated wi th a steep descendi ng l i mb (Fi g. 23.55).
Secreti ons
Secret i ons i n t he t racheal tube wi l l cause a sawt ooth pat t ern i n the pressure- and
f low-volume l oops (83,91) (Fi gs. 23.56, 23.57).
Pediatric Patients
Pedi at ric pati ents requi re a di ff erent scal e f or pressure- and f l ow-v ol ume loops.
Smal l pati ents requi re relati vel y hi gh ai rway pressures because of the small
di ameter of the t racheal tube. An exampl e is f ound i n Fi gure 23.45.
Spontaneous Breathi ng duri ng Controll ed Venti lation
I t i s possi bl e f or a nonparal yzed pat i ent to breathe spontaneousl y duri ng cont rol l ed
venti l ati on. Thi s can occur at any ti me duri ng the respi ratory cycl e. The
spontaneous breath usual l y has a lower i nspi ratory f l ow t han t he mechani cal
breat h.

View Figure

Figure 23.48 Flow-volume loop with increased resistance.
The dotted line represents the curve with normal resistance.
With increased resistance, there is diminished expiratory
flow. The convex configuration of the expiratory limb
reflects uneven lung emptying.

P. 759

View Figure

Figure 23.49 With a severe increase in resistance, the
ventilator cannot fully compensate, and inspiratory flow will
be diminished. Tidal volume may be decreased. Expiratory
flow is also severely decreased. The dotted line represents
the normal curve.

Fi gure 23. 58 shows a pressure-vol ume l oop wi t h a spontaneous breath during
exhal ati on. As the spontaneous breath occurs, the pressure drops bel ow the
expected l evel whi l e the vol ume ri ses above t he usual curve. As the spontaneous
breat h is exhal ed, t he pressure i ncreases bri efl y and t he vol ume drops rapi dl y. The
remai nder of the l oop f ol l ows the expected shape.
Fi gure 23. 59 shows a seri es of pressure-vol ume loops wi th t he sol i d l i ne (l oop 1)
representi ng a normal l oop produced wi th mechani cal vent i l ati on. Loops 2 and 3
show t he pati ent breathi ng agai nst the venti l ator. The l oop moves toward t he
negat ive side of the pressure axi s and then changes t o posi t ive. The pressures
generated are qui t e high and the t i dal volume i s decreased si nce t he pati ent i s
exhal ing duri ng i nspi rati on.
Flow-volume Loop
Fi gure 23. 60 depicts a f l ow-vol ume l oop wi th a spontaneous breath near the end of
i nspi rati on. There is a sudden i ncrease i n i nspi ratory fl ow and volume. As t he
breat h is exhal ed, t he f l ow and vol ume move t oward zero.

View Figure

Figure 23.50 With severe COPD, resistance during
expiration is greatly increased. The patient may have
difficulty exhaling completely before the next inspiration,
producing an open loop. COPD, chronic obstructive
pulmonary disease.

P. 760

View Figure

Figure 23.51 With severe COPD, expiratory flow is
severely reduced. COPD, chronic obstructive pulmonary
disease.

View Figure

Figure 23.52 Flow-volume loop with fixed intra- or
extrathoracic obstruction.

View Figure

Figure 23.53 A variable obstruction located outside the
thorax will cause a plateau during inspiration. The
expiratory portion of the curve is close to normal. The
dotted line shows a normal loop.

P. 761

View Figure

Figure 23.54 With a variable intrathoracic obstruction (such
as a tumor in the trachea or a mediastinal mass), inspiratory
flow may be relatively normal, but during expiration, flow
rises to a plateau instead of the usual rise to and descent
from peak flow. The dotted line shows a normal loop.

View Figure

Figure 23.55 With a restrictive defect, the increase in
elastic recoil is associated with higher expiratory flows. As
the process becomes more severe and lung volumes are
decreased, the flow-volume curve becomes tall and narrow.
The dotted line shows a normal loop.

View Figure

Figure 23.56 Pressure-volume loop with secretions in the
tracheal tube.

P. 762

View Figure

Figure 23.57 Flow-volume loop with secretions in the
tracheal tube.

Open Loop
A loop shoul d return to i ts start i ng poi nt at t he end of the respi rat ory cycl e. An open
l oop (Fig. 23.61) has a gap bet ween the end and start ing poi nts, indi cat ing that the
exhal ed vol ume i s l ess than t he i nhal ed volume. Whi le t he pressure-vol ume l oop
appears to cl ose, i t actual l y ret urns to zero pressure al ong the vert ical axi s rather
t han at t he st arti ng poi nt . The amount of gas l oss can be read between zero and
t he return poi nt of t he l oop.
An open l oop means that more gas has passed the sensor duri ng i nspi rat i on than
returns duri ng exhal ati on. Most of ten, t hi s is because of a leak di stal t o the sensor.
I ncorrect cali brati on shoul d al so be consi dered. An open loop is of ten seen wi th
mask anest hesi a, an uncuf f ed t racheal tube, or a supragl ot ti c ai rway devi ce. A
doubl e-l umen tube may i mpose suf f i ci ent resi st ance t o resul t i n the l ungs not
compl etel y empt yi ng, even i n pati ents wi t h normal ai rways (22,92).
Leaks of ten occur af ter l ung reducti on or other thoraci c surgery (93). The extent of
t he l eak and changes i n the vol ume of gas l ost can be t racked wi th t he f l ow-vol ume
l oop.
An open l oop may be due to i ncomplete exhal at ion caused by chroni c obst ruct ive
pul monary di sease (COPD), i ncreased resi stance caused by apparatus, a tension
pneumothorax, l ung ret racti on, or a fl ap-valve obst ructi on i n a l arge ai rway or a
doubl e-l umen tube (94).
Overshoot Loop
An overshoot l oop i ndicates t hat the exhal ed volume i s greater than the i nspi red
volume. Thi s usual l y i ndi cates
P. 763

t hat the moni tor needs to be recal i brated. It can al so resul t i f pressure on t he
t horax causes some of the f uncti onal resi dual vol ume to be added to t he ti dal
volume.

View Figure

Figure 23.58 This spontaneous breath occurs during
expiration.

View Figure

Figure 23.59 Loop 1 represents the normal loop. Loop 2
shows a spontaneous breath during inspiration. The pressure
drops, and the volume increases briefly. There is a decrease
in compliance caused by an increase in tension in the chest
wall muscles. In loop 3, the patient inhales at the beginning
of the respiratory cycle, so the loop moves to the left of the
vertical axis. There is a further decrease in compliance.

The pressure-vol ume overshoot l oop (Fig. 23. 62) can appear as a normal l oop, but
t he begi nni ng poi nt is to the right of t he endpoi nt . The di f f erence bet ween the
beginni ng and endpoi nt i s the amount of excess gas t hat is exhal ed.
Flow-volume Loop
On the overshoot f low-volume l oop (Fig. 23.63), t he endpoint is t o the ri ght of the
zero vol ume point . The distance to t he ri ght represents the excess gas that has
been exhaled.
Intrinsi c Positive End-expiratory Pressure and Air Trappi ng
I ntri nsi c (auto, occul t ) PEEP (PEEPi ) resul ts f rom a di ff erence between the actual
expi ratory t i me and the
P. 764

expi ratory t i me requi red for compl et e exhalati on of t he ti dal vol ume so t hat some
ai r i s t rapped i n the l ungs (Fi g. 23.63). It may be generated by a very short
expi ratory t i me and/ or sl ow expi rati on due to hi gh resi stance or abnormal l y hi gh
compl i ance. Ai r t rapping is l ikel y to occur i n pati ents wi th ai rf l ow l i mi t at ion, i nverse
rati o venti lati on, or when using a high respiratory rate.

View Figure

Figure 23.60 The spontaneous breath occurs near the end of
inspiration. The thin, dotted line represents the normal loop.
Instead of returning to zero at the end of inspiration, the
flow increases. There is a small increase in volume as well.

View Figure

Figure 23.61 There is a leak, so exhaled volume is
approximately 150 mL less than the inhaled volume. This
produces open pressure-volume and flow-volume loops.

Loops Representing Equipment Problems
Tubing Misconnection
Some ol der sensors had a l ong and a short ni ppl e designed to connect to the short
and l ong l umens of the pressure tubing, respecti vel y. It was possible t o connect the
t ubi ngs l ong t o l ong and short t o short. If thi s were done, the moni t or woul d sense
exhal ati on as i nhalati on and vi ce versa. The l oops woul d be drawn backward and
upside down (Fi g. 23. 64). It woul d t ake t wo respi ratory cycl es to produce a f ul l
l oop, and the moni tor woul d be unabl e to compute the compl i ance. Extremel y hi gh
PEEP val ues woul d be recorded. Newer sensors wi th mal e and female connecti ons
make tubi ng mi sconnecti ons l ess l ikel y (Fi g. 23.8).
Disconnecti on between the Sensor and the Breathing
System
I f there i s a disconnecti on bet ween the spi rometry sensor and the breathi ng
system, there wi l l be no f l ow
P. 765

t hrough the sensor duri ng mechani cal vent il at ion and a loop wi l l not be generated
(Fi g. 23.65).

View Figure

Figure 23.62 The exhaled volume exceeds the inhaled
volume, producing an overshoot loop.

View Figure

Figure 23.63 Intrinsic positive end-expiratory pressure and
air trapping. The gap in the flow-volume loop indicates that
there was still expiratory flow when the next inspiration
commenced. PEEP, positive end-expiratory pressure.

I f the pati ent breathes spontaneousl y wi t h a disconnecti on bet ween t he sensor and
t he breathi ng system, l oops seen wi th spontaneous respi rati on wi l l be generated. I f
a ci rcle breathi ng system al so contains a f low sensor mount ed on the exhalati on
si de near the absorber, t hi s sensor wi l l not i ndi cat e f l ow duri ng spontaneous
venti l ati on and wi l l hel p to l ocal i ze the di sconnecti on.
Leak between the Sensor and the Breathing System
I f there i s a l eak or parti al disconnecti on bet ween the sensor and t he breathi ng
system, some gas wi l l be l ost . The pressure-v ol ume loop (Fi g. 23.66) wi l l be normal
i n shape but wi l l show a decrease i n t idal volume and a decrease i n peak ai rway
pressure. Thi s di ff ers f rom the l eak associ at ed wi t h the open l oop i n t hat the
i nhal ed volume i s decreased as a resul t of the l eak, but the amount of gas exhaled
i s equal to the amount of gas i nhal ed.
Flow-volume Loop
The f low-v ol ume l oop duri ng a part i al disconnecti on (Fi g. 23.66) wi l l show a
decreased t idal volume and a decrease i n peak expi ratory f l ow. The loop wi l l not be
open because both i nspi red and exhal ed ti dal vol umes wi l l be the same.

View Figure

Figure 23.64 Misconnection of the tubings will cause the
loop to be drawn backward and upside down.

P. 766

View Figure

Figure 23.65 A disconnection between the sensor and the
breathing system will result in no flow through the sensor.

Disconnecti on between the Sensor and the Pati ent
Wi th a di sconnecti on bet ween the sensor and the pati ent , duri ng control l ed
venti l ati on there wi l l be f l ow duri ng i nspi rati on but not exhal at ion (Fi g. 23.67). The
pressure-volume l oop wi l l show a hi gh ti dal vol ume but al most no pressure. Si nce
t here wi l l be no return gas f l ow, t here wi l l be onl y hal f of a pressure- or f l ow-v ol ume
l oop.
Bronchial I ntubation
Bronchial intubat ion can occur anyti me a t racheal tube is i n pl ace. It i s the most
f requent l y occurri ng probl em leadi ng to hypoxia (95). If t hi s happens, the
compl i ance decreases and t he pressure needed to del iver a set t i dal volume ri ses
(21,96,97). Bronchi al int ubati on i s discussed i n Chapter 19. It i s most l i kel y t o
occur wi t h a change i n the pati ent ' s posi ti on. If a sudden change occurs i n the
pressure-volume l oop at thi s t i me, bronchi al i ntubati on shoul d be suspect ed.
Wi thdrawi ng t he tracheal t ube sl i ght l y wi l l remedy the problem and wi l l be
demonst rated wi th t he next loop. Pressure-vol ume loops may be among t he best
ways of detect i ng this probl em.
The pressure-vol ume l oop wi l l show a decrease i n compl i ance wi t h a ri ghtward and
downward shi f t and a high peak pressure (Fi g. 23.68, sol id l i ne).

View Figure

Figure 23.66 With a leak between the sensor and the
breathing system, the loop will have a normal shape but the
tidal volume, peak pressure, and expiratory flows will be
decreased. The dotted line represents the normal loop, and
the solid line represents the loop with a leak.

P. 767

View Figure

Figure 23.67 A disconnection distal to the sensor will result
in flow during inspiration but none during exhalation.

Flow-volume Loop
The f low-v ol ume l oop associated wi t h bronchi al i ntubat i on is shown i n Figure 23.69
(sol id l ine). The increase i n peak pressure wi l l i ncrease the peak f l ow duri ng
exhal ati on.
Double-l umen Bronchial Tube Problem
Double-l umen bronchi al t ubes are of ten pl aced incorrectl y or may be di spl aced
duri ng pat ient posi ti oni ng or surgery (6,21, 22, 98,99,100). Conti nuous spi rometri c
moni tori ng can hel p to det ect the probl em. Basel i ne fl ow-vol ume and pressure-
volume l oops shoul d be establ i shed and recorded f or each pat ient whi le i n the
supine posi t ion duri ng two-l ung vent i l at ion t o al low comparison wi t h later l oops.
When one-l ung venti l at ion i s begun, t he pressure-volume l oop shoul d show a sl i ght
shif t of the sl ope to the ri ght, ref l ect ing decreased compl i ance (98,99, 100). Wi th
surgi cal handl i ng of t he nondependent l ung, compl i ance may decrease f urt her
(100).
I f a double-l umen tube is pl aced too deepl y, t here wi l l appear to be a decrease i n
compl i ance (Fi g. 23.70). Tidal volume may be decreased. Incomplete l ung empt yi ng
wi l l resul t in an open loop (22).
The l oops shown i n Figure 23.71 resul ted f rom the t i p of the bronchi al l umen
i mpingi ng on the wal l of the bronchus. Loop 1 (sol i d l i ne) i s the normal l oop. I n l oop
3 (dott ed l ine), t he tube t ip has i mpi nged on t he wal l of the bronchus. Pressure
ri ses rapidl y wi th l i t tl e i ncrease i n vol ume unt i l suf f i ci ent pressure has been
P. 768

P. 769

exert ed to move the t ip away f rom the wal l . At t hi s poi nt, the volume ri ses rapi dl y.
There wi l l be an increase i n peak pressure and/or a decrease in compli ance. If
t here i s a bal l -valve acti on, duri ng exhal at i on the pressure wi l l decrease rapi dl y
wi th l i t t l e change i n vol ume unt i l the pressure i n the bronchi al tube has fal l en
suff icientl y to al l ow exhal ati on.

View Figure

Figure 23.68 Bronchial intubation (solid loop) will result in
a decrease in compliance.

View Figure

Figure 23.69 Bronchial intubation. The solid loop shows an
increase in expiratory flow, especially during the early part
of expiration.

View Figure

Figure 23.70 The dotted line represents the loop when the
double-lumen tube is correctly positioned. If the bronchial
lumen is inserted too deeply, a severe reduction in
compliance and tidal volume will be seen.

View Figure

Figure 23.71 Impingement of the end of the tube on the
bronchial wall has created a ball-valve obstruction. The
pressure rises rapidly with little increase in volume until the
pressure is sufficient to overcome the obstruction. The
volume then increases, and the pressure drops. If the
pressure drops low enough, there will again be obstruction
to flow, creating another notch on the upswing of the loop.

Flow-volume Loop
The f low-v ol ume l oop duri ng proper double-l umen tube pl acement wi l l show a
sl i ght ly decreased expi ratory f l ow rate. If t he tube is placed too deepl y i nto the
bronchus, the l oop wi l l show di minished i nspi ratory and expi rat ory f l ows. If t here is
a bal l -valve obst ructi on t o the t ip of the doubl e-l umen tube, the f l ow-vol ume l oop
wi l l be i rregul ar (Fi g. 23. 72).
The f low-v ol ume l oop that woul d be generated i f there were a di sconnect i on of one
l i mb of a doubl e-l umen tube or a l eaki ng bronchi al cuf f is shown i n Fi gure 23.73
(sol id l ine). The inspi ratory porti on i s normal . Because much of the i nspi red ti dal
volume i s lost t hrough the leak, the l oop is open. I n addi t ion, there wi l l be
decreased f low duri ng exhal ati on.

View Figure

Figure 23.72 The loop represents repeated ball-valve
obstruction to flow during both inspiration and expiration.

P. 770

View Figure

Figure 23.73 With a leak in the bronchial cuff or a
disconnection of one limb (solid loop), there will be an open
loop, with the inhaled volume exceeding the exhaled
volume. Exhaled flows will be decreased.

Esophageal I ntubati on
Wi th esophageal i nt ubat i on, the pressure-volume l oop wi l l usuall y show a decrease
i n compl i ance (Fig. 23.74, sol i d l ine), al t hough compl i ance may be increased or
normal (21). Gas that enters the stomach and i s not returned wi l l create an open
l oop. The f l ow-vol ume l oop wi l l be distort ed and show smal l inspi ratory and
expi ratory vol umes, of ten wi th an open loop.
Obstructed Tube
A nearl y compl etel y obst ructed t racheal t ube or an i ncorrect l y placed supraglott ic
ai rway devi ce wi l l resul t in a pressure-volume l oop t hat shows a hi gh pressure wi th
l i t tl e or no t idal volume (Fi g. 23.75). This i s usual l y a si gnal that the devi ce shoul d
be removed and rei nserted.
Advantages of Loop Technology
Pressure- and f l ow-vol ume l oops provide the cl i nician wi t h real -ti me inf ormat ion.
There are many probl ems that can occur unexpectedl y duri ng a case (e.g., kinked
t racheal tube, di sconnecti on, migrat ion of a tracheal t ube i nto a bronchus). Wi thout
l oops, these probl ems mi ght not be recognized promptl y and correct i ve act ion may
be delayed. Whi l e many of t he probl ems that occur duri ng respi rati on coul d be
determined by wat chi ng
P. 771

pressure, ti dal vol ume, and f l ow moni tors, loop technol ogy off ers a graphic
representati on that i ntegrates that i nf ormati on, maki ng changes more obvious.

View Figure

Figure 23.74 The loops associated with esophageal
intubation may vary greatly. Compliance may be increased,
decreased, or normal.

View Figure

Figure 23.75 With a nearly obstructed tube, there will be a
high pressure with little volume.

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P. 773

Questions
For the f ol lowing quest ions, sel ect t he correct answer
1. Normal static compliance i n an adul t is
A. 15 mL/cm H
2
O
B. 35 to 100 mL/cm H
2
O
C. 20 t o 35 mL/cm H
2
O
D. 35 t o 50 mL/cm H
2
O
E. 75 to 125 mL/cm H
2
O
Vi ew Answer2. For greatest accuracy, the gas flow sensor should be
pl aced
A. I n the i nspi rat ory l i mb at the absorber
B. Between the i nspi ratory l i mb and the Y-pi ece
C. Between the Y-pi ece and the pat i ent
D. Between the Y-pi ece and the expi rat ory l i mb
E. On the absorber on the exhalat i on si de
Vi ew Answer3. The preferred si te for monitori ng airway pressure is
A. At the vent il ator
B. I n the i nspi rat ory l i mb at the cani ster
C. At t he connecti on bet ween t he pati ent and the breathi ng system
D. On t he expi ratory l imb at t he cani ster
E. At the bag mount connecti on
Vi ew AnswerFor the fol l owing quest i ons, answer
i f A, B, and C are correct
i f A and C are correct
i f B and D are correct
i s D i s correct
i f A, B, C, and D are correct .
4. What does the difference between the peak and plateau pressure measure?
A. Pl at eau pressure
B. Total ai rway resi stance
C. Compl i ance
D. I nspi ratory f l ow
E. Resi stance i n t he breathi ng system
Vi ew Answer5. Use of muscle rel axants
A. May cause t he compl i ance of the l ungs to i ncrease
B. May cause t he compl i ance of the chest wal l to i ncrease
C. May cause a decrease i n resi st ance
D. May resul t i n a decrease in pl ateau pressure
Vi ew Answer6. A rise i n peak ai rway pressure may occur as a result of
A. An i ncrease in t idal vol ume
B. An i ncrease in i nspi ratory f l ow rate
C. An i ncrease i n resi stance
D. An i ncrease i n compl i ance
Vi ew Answer7. Wi th i nadvertent bronchial intubati on,
A. There wi l l be a decrease in compli ance
B. The pressure-vol ume loop wi l l be shi f ted to t he ri ght and downward
C. The peak pressure wi l l be increased
D. The f l ow-vol ume loop wi l l show an increase i n peak expi ratory f l ow
Vi ew Answer8. Increased resistance to breathi ng during control led
respi ration can be overcome by
A. Addi ng or i ncreasi ng PEEP
B. I ncreasing the driving pressure
C. I ncreasing t he i nspi red oxygen
D. Decreasi ng i nspi ratory f l ow
Vi ew Answer9. Total resistance during inspi ration and expi ration is
i nfl uenced by
A. The pat ient' s ai rway
B. The exhalat i on porti on of the breathi ng system
C. The size and characteri st ics of the t racheal t ube
D. The amount of PEEP added to the breat hi ng system
Vi ew Answer10. Means to detect a leak around a tracheal tube i ncl ude
A. Ai rway pressure moni tors
B. Respi ratory breath sound moni t oring
C. Respi rat ory vol ume measurement
D. Capnography
Vi ew Answer11. Respi ratory vol ume monitori ng may fail to detect
A. Occl usi on of the ai rway
B. A di sconnecti on duri ng spontaneous breathi ng
C. Esophageal int ubati on
D. Apnea
Vi ew Answer12. Which factors are components of total compliance?
A. El asti c properti es of the l ungs
B. El asti c properti es of the t horax
C. El asti c properti es of t he abdomen
D. El asti c properti es of t he breat hi ng system
Vi ew Answer13. Condi ti ons that can be detected by using a minimum
pressure alarm include
A. An unconnect ed venti l ator
B. A maj or l eak i n the breat hi ng system
C. A mal f unct ioning scavengi ng system
D. An i ncrease i n resi stance
Vi ew Answer14. The minimum airway pressure alarm shoul d be set
A. At the l owest set ti ng
B. At dif f erent set t ings during a case
C. Greater t han 6 cm H
2
O
D. Sl i ght ly l ess t han t he peak pressure duri ng i nspi rat ion
Vi ew Answer15. Condi ti ons that may prevent activati on of the mi ni mum
pressure alarm with a disconnecti on include
A. Obstruct i on of a breathi ng system connector
B. Part ial ext ubati on
C. Hi gh resi stance of components of the breathing system
D. Ai r entrai ned into the breathing syst em
Vi ew Answer16. A sustained pressure may be caused by
A. Occl usi on of the scavenging system
B. Acti vat i on of t he oxygen f l ush val ve
C. I mproper adjustment of the APL valve
D. Occlusi on of the inspi ratory l i mb of the breathing syst em
Vi ew Answer17. An excessi vely high pressure i n the breathing system
may be caused by
A. The pat ient coughi ng or st raini ng
B. Use of the oxygen f l ush duri ng the inspi rat ory phase of the vent il ator cycl e
C. A punctured venti l at or bell ows
D. I ncreased compl i ance
Vi ew AnswerP. 774

18. Subambient pressure i n the breathing system may be caused by
A. A nasogastri c tube placed i n the trachea and at t ached t o sucti on
B. A bl ocked expi ratory l i mb
C. I nspi rat ion wi t h an empty reservoi r bag
D. Refi l l i ng of a venti l ator wi t h a standi ng bel l ows wi th l ow f resh gas f lows
Vi ew Answer19. On a pressure-vol ume loop,
A. The farthest point to the ri ght on the hori zontal axi s represents the ti dal vol ume
B. The sl ope of the inspi ratory porti on i s det ermi ned by t he resi st ance
C. The highest poi nt on t he curve represent s the peak pressure
D. The curve can sl ope to the ri ght or l ef t duri ng inspi rat i on
Vi ew Answer20. Concerni ng a fl ow-volume l oop,
A. The porti on bel ow the hori zontal l i ne represents i nspi rat ion using the
representati on used by pul monol ogi sts
B. The porti on above the hori zontal l i ne represents t he passive def lat i on as
determined by the elasti c recoi l of the l ungs and chest wal l i n the representati on
used by pul monologists
C. The t i dal vol ume is that point where the l oop crosses t he hori zont al l ine
D. This l oop i s known as a compl iance loop
Vi ew Answer21. If a double-l umen tube is pl aced too deepl y,
A. The pressure-vol ume loop wi l l be shi f ted to t he ri ght and downward
B. There wi l l be a decrease in compli ance
C. An overshoot loop may resul t
D. Resistance wi l l i ncrease
Vi ew Answer22. Possibl e causes of inadvertent PEEP i ncl ude
A. Part ial obstruct ion of the breathing system
B. Mal f unct i oni ng scavengi ng devi ce
C. Obstructi ve ai rway disease
D. Ai rf l ow obst ruct ion
Vi ew Answer23. Possibl e causes of an open l oop i ncl ude
A. I mproper cal ibrat ion of the moni t or
B. An uncuf fed t racheal tube
C. A l eak di stal t o the sensor
D. Tensi on pneumothorax
Vi ew Answer24. Decreases in compl iance may be caused by
A. I nadequate muscle rel axat i on
B. Bronchi al i ntubat ion
C. Obesi ty
D. Reverse Trendel enburg posi ti on
Vi ew Answer25. With restri ctive l ung disease,
A. Peak expi ratory f low wi l l be increased
B. The f l ow-vol ume l oop may become tal l and narrow
C. The f l ow-vol ume loop may have a relati vel y normal shape but may appear
smal l er i n all di mensi ons
D. Resistance i s i ncreased
Vi ew Answer

Chapter 23. Airway Volumes, Flows, & Pressures

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Airway Volumes, Flows, and Pressures

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Chapter 23. Airway Volumes, Flows, & Pressures

Chapter 23. Airway Volumes, Flows, & Pressures