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💨 Vent Pattern Lab

Mechanical ventilation waveforms, modes, and clinical decision-making. LectiGuide's first specialty module.

💡 New to mechanical ventilation? Start with the Intro Podcast to build your foundation, then explore the Waveform Library beginning with Normal VCV.
Sections
📊 Waveform Library
Select a pattern to study all 3 scalars
Select a pattern to study
🔬 Mode Taxonomy
TAG builder, advanced modes, NAVA & manufacturer guide
Equation of Motion
Pmus + Pvent = (E × V) + (R × V̇)
Elastic load + Resistive load. The ventilator and/or patient muscles must overcome both.
Mode TAG Builder
Every mode = Control Variable + Breath Sequence + Targeting Scheme
+ +
Mode Performance at a Glance
Mode TAGMV ControlVILI Prot.SynchronyWOBLiberation
Manufacturer Name Translator
Same mode, different names across manufacturers
🔄 Limit vs Cycle — Key Distinction
Limit
A limit caps a variable at a set value but does not end the breath. Inspiration continues at the limit until the cycle criterion is met. Example: a pressure limit of 40 cmH₂O means pressure cannot exceed 40 but the breath keeps going until time or flow cycles it off.
Cycle
A cycle ends the breath. When the cycle criterion is reached, inspiration terminates and exhalation begins. Common cycle mechanisms: time (Ti set), flow (drops to % of peak — PSV), volume (Vt reached — VCV), pressure (pressure-cycled vents).
Clinical pearl: PSV is flow-cycled. The breath ends when inspiratory flow drops to a set % of peak flow (typically 25%). If a patient has an air leak, flow never drops low enough — the breath cycles late (late cycle / prolonged inspiration). This is why patients with ETT cuff leaks often dyssynchronize on PSV.
🔬 Advanced Modes
Modes beyond the 4 major modes — commonly seen in ICU and specialty settings.
PRVC — Pressure Regulated Volume Control
Adaptive
PRVC combines the benefits of volume and pressure control. The ventilator delivers a pressure-controlled breath but automatically adjusts the inspiratory pressure breath-by-breath to achieve a target tidal volume. If compliance improves, pressure decreases. If compliance worsens, pressure increases — never exceeding a set ceiling.
Control variablePressure (adaptive)
TargetSet tidal volume
WaveformDecelerating flow
Use whenChanging compliance
Manufacturer names: AutoFlow (Dräger) · VC+ (Puritan Bennett) · APVcmv (Hamilton) · PRVC (Maquet SERVO)
APRV — Airway Pressure Release Ventilation
ARDS / Trauma
APRV holds the lungs at a high CPAP level (P-high) for most of the breath cycle, with brief releases to a low pressure (P-low) to allow CO₂ elimination. The patient breathes spontaneously throughout at P-high. This recruits and maintains alveolar volume while allowing ventilation during the release phase.
P-high20–30 cmH₂O (recruitment)
P-low0–5 cmH₂O (release)
T-high4–6 seconds
T-low0.4–0.8 seconds
Used for: severe ARDS, trauma, refractory hypoxemia. Goal is lung recruitment while preserving spontaneous breathing.
VAPS — Volume Assured Pressure Support
Neuromuscular
VAPS delivers pressure support but guarantees a minimum tidal volume. If the patient generates enough effort on their own, the breath is purely pressure-supported. If effort falls short of the target Vt, the ventilator switches to volume delivery mid-breath to make up the difference. Protects patients with variable or unreliable respiratory drive.
Used for: neuromuscular disease, chest wall disorders, weaning patients with inconsistent effort. Combines comfort of PSV with safety of volume guarantee.
Bilevel / BiPAP — Two-Pressure Ventilation
Non-Invasive / Invasive
Bilevel ventilation delivers two alternating pressure levels — IPAP (inspiratory positive airway pressure) and EPAP (expiratory positive airway pressure). The ventilator cycles between the two pressures, and the patient can breathe spontaneously at both levels. Used invasively (as a mode) and non-invasively (mask BiPAP).
IPAPHigher pressure (inspiration)
EPAPLower pressure (= PEEP)
PS levelIPAP − EPAP
Used forCOPD, Type II failure, sleep apnea
Non-invasive BiPAP is a first-line intervention for COPD exacerbations and acute cardiogenic pulmonary edema — often avoids intubation.
NAVA — Neurally Adjusted Ventilatory Assist
Advanced / NICU
NAVA bypasses airway triggering entirely. A specialized nasogastric catheter with embedded electrodes — the Edi catheter — detects the electrical activity of the diaphragm (Edi signal) directly from the respiratory center. The ventilator delivers pressure support proportional to the neural drive, eliminating trigger delay almost completely.
Trigger mechanismEdi signal (neural)
Key settingNAVA level (cmH₂O/μV)
WaveformEdi alongside standard scalars
Available onGetinge/Maquet SERVO only
Higher NAVA level = more pressure support per microvolt of Edi. Titrated to achieve target tidal volumes without over-assisting. If Edi catheter is displaced or signal lost — ventilator falls back to conventional triggering.
🏥 Clinical pearl: NAVA is commonly seen in NICUs for premature infants with immature and irregular respiratory drive. Traditional pressure and flow triggers are unreliable at the very low tidal volumes of neonates. NAVA provides synchrony that conventional modes cannot match at that scale — the neural signal drives the breath before any mechanical effort begins.
📋 PVI Guide
Reading rules, P-V loops, flow-volume, capnography & discordance
6 Key Waveform Reading Rules
PVI Classification
Discordance Management
Tap any type to see management strategies
📉 P-V Loop Interpretation
Pressure-Volume loops display the relationship between airway pressure and tidal volume for each breath. Direction and shape reveal compliance, resistance, and work of breathing.
Loop Direction
Anti-clockwise (VCV)
Volume control with constant flow. Inspiration goes up and right, expiration returns lower left. Normal loop direction for VCV.
Box-shaped (PCV)
Pressure control with decelerating flow. Loop appears more rectangular. Cannot assess compliance slope from this loop shape.
Clockwise (Spontaneous)
CPAP or spontaneous breathing. Direction reverses because patient generates negative pressure to initiate flow.
Work of Breathing
The area enclosed by the P-V loop represents work of breathing. Larger loop area = more work performed that breath.
Inflection Points — The Clinical Gold
Lower Inflection Point (LIP)
The point where the loop bends upward steeply from a flat lower segment. Represents the lung opening pressure — the pressure at which collapsed alveoli begin to recruit. Ideal minimum PEEP should be set at or slightly above the LIP to keep alveoli open between breaths.
Upper Inflection Point (UIP) — Beak Sign
The point where the loop flattens at the top and bends back — creating a beak or hook shape. Represents overdistension. Alveoli are at maximum stretch and volume is no longer increasing with pressure. If tidal delivery reaches the UIP — reduce Vt or PEEP immediately to prevent barotrauma.
Loop Shape Changes — What They Mean
Compliance decreased (stiff lungs)
Loop becomes flatter and wider — more pressure required for same volume. Slope of the loop decreases. Seen in ARDS, pulmonary edema, pneumonia, pneumothorax.
Resistance increased (airway obstruction)
Loop shifts position but slope (compliance) remains the same. The inspiratory and expiratory limbs separate further — wider loop. The pressure difference between inspiration and expiration increases. Seen in bronchospasm, secretions, COPD.
Auto-PEEP on P-V loop
Loop does not return to zero pressure at end-expiration. The starting point of the next breath is shifted to the right — above zero. Confirms air trapping even when the flow-time scalar appears normal.
Quick Reference — P-V Loop Findings
• Flat wide loop → low compliance
• Beak at top → overdistension
• Wide limbs → high resistance
• LIP visible → set PEEP above it
• Loop shifts right → auto-PEEP
• Larger area → more WOB
🌀 Flow-Volume Loop
Flow-Volume loops plot flow rate against volume delivered. Shape reveals airway patency, obstruction, and secretion burden.
Normal Flow-Volume Loop
Inspiratory limb: smooth rise to peak flow then gradual descent as volume fills. Expiratory limb: rapid rise to peak expiratory flow then gradual return to zero as lungs empty. The loop closes cleanly at zero — no residual flow at end-expiration.
Saw-Tooth Pattern — Secretions
Irregular serrations or notches on both the inspiratory and expiratory limbs. Caused by secretions or mucus moving in the airway as gas flows past. Clinical action: suction the patient. If the saw-tooth pattern disappears after suctioning — confirmed secretions. If it persists — consider other causes (water in circuit, airway instability).
Obstructive Pattern
Expiratory limb shows a scooped or concave shape — flow drops off rapidly after peak then tails slowly toward zero. The loop may not fully close, indicating air trapping. Seen in COPD, asthma, and bronchospasm. The more severe the obstruction, the more pronounced the scoop.
Variable Upper Airway Obstruction
Flattening of the inspiratory limb with a normal expiratory limb. Caused by upper airway obstruction that collapses during inspiration (tracheomalacia, vocal cord dysfunction, partial ETT obstruction). If both limbs are flattened — fixed obstruction.
💨 Capnography — CO₂ Waveform
Capnography continuously measures exhaled CO₂ in real time. The waveform shape and etCO₂ value together tell you about ventilation, perfusion, and airway patency.
Normal Capnogram — Four Phases
I
Inspiratory baseline (zero) — CO₂-free gas from dead space. Flat at zero. Should be at baseline — elevated baseline means rebreathing.
II
Expiratory upstroke — rapid rise as alveolar gas mixes with dead space gas. Should be steep. Sloped upstroke = obstructive disease.
III
Alveolar plateau — flat or slightly rising segment. Peak = etCO₂. Normal: 35–45 mmHg. Upward sloping plateau = V/Q mismatch or obstructive disease.
IV
Inspiratory downstroke — rapid fall back to zero as fresh gas washes out CO₂. Should be sharp and steep.
Waveform Variants — What Each Means
Sudden drop to zero
Complete loss of etCO₂. Causes: esophageal intubation, circuit disconnect, cardiac arrest, ET tube dislodgement. Immediate action required.
Shark Fin pattern
Upstroke is sloped (not sharp), plateau rises continuously, no flat alveolar plateau. Looks like a shark fin. Classic sign of bronchospasm or severe obstruction (asthma, COPD exacerbation). The more severe the obstruction, the more pronounced the fin shape.
Elevated baseline
Baseline does not return to zero between breaths. Indicates CO₂ rebreathing. Causes: exhausted CO₂ absorber (circle system), incompetent expiratory valve, insufficient fresh gas flow.
Gradual decrease in etCO₂
Progressive decline over several breaths. Causes: hyperventilation (too high RR or Vt), decreasing cardiac output, pulmonary embolism (decreased perfusion = less CO₂ exhaled).
Curare cleft — notch in plateau
A dip or notch in the alveolar plateau. Sign of patient respiratory effort during controlled ventilation. Patient is trying to breathe against the ventilator during the expiratory phase. Indicates the patient may be waking up from sedation or paralysis.
etCO₂ Quick Reference
Normal: 35–45 mmHg
Low: hyperventilation, PE, low CO
High: hypoventilation, increased metabolism
Zero: disconnect, arrest, esophageal
🔧 Clinical Tools
Formulas, alarms, disease settings, checklist & PEEP tables
Ventilator Assessment Checklist
Work through all 5 questions for every patient assessment.
Safe Ventilation Targets
ARDSnet PEEP/FiO₂ Tables
Find FiO₂ on top row to get PEEP target
Low PEEP Table
High PEEP Table
📏 Key Formulas
Minute Ventilation (V̇E)
V̇E = Vt × RR
Normal: 5–10 L/min · Adult resting ~500 mL × 12 = 6 L/min
Dynamic Compliance (Cdyn)
Cdyn = Vt ÷ (PIP − PEEP)
Reflects airways + alveoli · Normal: 40–60 mL/cmH₂O · Affected by resistance AND compliance
Static Compliance (Cstat)
Cstat = Vt ÷ (Pplat − PEEP)
Reflects alveoli only · Normal: 60–100 mL/cmH₂O · Requires inspiratory hold
Airway Resistance (Raw)
Raw = (PIP − Pplat) ÷ Flow (L/s)
Normal intubated: 5–10 cmH₂O/L/s · PIP rises, Pplat unchanged = resistance problem
Mean Airway Pressure (P̅aw)
P̅aw = average pressure across total cycle time
Primarily influenced by PEEP · Also affected by PIP, Ti, RR · Higher MAP = more cardiac impairment
Plateau Pressure (Pplat) — Clinical Significance
Reflects peak alveolar pressure. Target <30 cmH₂O to prevent barotrauma and volutrauma. If Pplat >30: decrease Vt or switch to PCV. Driving pressure = Pplat − PEEP. Target driving pressure <15 cmH₂O in ARDS.
🔔 Alarm Settings Reference
Set relative to measured values. If alarm source not quickly identified — manually ventilate.
Alarm High Limit Low Limit
PIP / PAP +10–15 cmH₂O above measured −10–15 cmH₂O below measured
Tidal Volume +100–200 mL above exhaled Vt −100–200 mL below exhaled Vt
Minute Volume 1.5× measured V̇E 1–2 L below measured V̇E
Respiratory Rate 1.5× measured RR —
PEEP / CPAP — 2–3 cmH₂O below set PEEP
FiO₂ +0.05 from set −0.05 from set
High PIP
Secretions · Kinked or bitten ETT · Blocked filter · Kinked inspiratory limb · Water in circuit · Bronchospasm · Decreased compliance
Low PIP / Low Vt / Low V̇E
Circuit disconnect · Circuit leak · Cuff leak or deflation · Hypoventilation
High RR / High V̇E
Hyperventilation · Auto-triggering · Patient agitation or pain
⚠ Safety Rule
If alarm source cannot be quickly identified — remove patient from ventilator and manually ventilate immediately.
🧬 Initial Settings by Disease
Always calculate Vt from IBW (height-based) — never actual weight. Start FiO₂ at 1.0 and wean as tolerated.
Normal Lungs
Vt: 6–8 mL/kg IBW
RR: 12–16 bpm
Flow: 40–100 L/min (start 60)
PEEP: +5 cmH₂O
Increase flow until it meets patient demand. Post-surgical and apneic patients.
COPD
Vt: 6–8 mL/kg IBW
RR: 10–12 bpm
Flow: Higher — increases Te
PEEP: +5 cmH₂O
Lower RR to allow longer Te and prevent air trapping. Chronic CO₂ retainers — expect elevated HCO₃.
ARDS / Restrictive
Vt: 4–6 mL/kg IBW
RR: 20–35 bpm
Flow: Per patient demand
PEEP: Per ARDSnet table
If Pplat >30 cmH₂O — switch to PCV. Non-homogenous compliance. Very prone to pneumothorax.
Severe Asthma
Vt: 4–6 mL/kg IBW
RR: 10–12 bpm
Flow: Higher — increases Te
PEEP: +5 (use caution)
Permissive hypercapnia: allow pH to fall to 7.25, PaCO₂ rise to 60 torr. Consider sedation/paralysis. Very low pressures — prone to pneumothorax.
IBW reminder: Cannot start every patient the same. Always verify Vt per kg IBW, RR for the disease, and flow to meet patient demand. Ask: Are they breathing? Any underlying issues? Do they need high O₂? What is their size?
Goal-Directed Mode Selection
🎧 Intro Podcast
4 episodes · Introduction to Mechanical Ventilation
These episodes are designed to give you a confident foundation before diving into waveform patterns. Listen in order, then open the Waveform Library and start with Normal VCV.
You are not expected to be an expert after this. Take it one step at a time. You have got this.
🧪 Vent Lab Test
6 patient scenarios · Select parameters · Clinical feedback
Select a patient scenario, calculate IBW, choose ventilator parameters, and get clinical feedback grounded in Egan's 12th edition.