HOW I TEACH

How I Teach Auto-PEEP

Applying the Physiology of Expiration
AUTHORS: Michael Keller1, Willard Applefeld1,2, Megan Acho3, and Burton W. Lee1
1
Department of Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland; 2Department of
Cardiology, Duke University School of Medicine, Durham, North Carolina; and 3Division of Pulmonary and Critical Care
Medicine, University of Michigan, Ann Arbor, Michigan

ABSTRACT

Teaching complex topics in mechanical ventilation can prove challenging for clinical
educators, both at the bedside and in the classroom setting. Some of these topics, such as
the topic of auto-positive end-expiratory pressure (auto-PEEP), consist of complicated
physiological principles that can be difficult to convey in an organized and intuitive man-
ner. In this entry of “How I Teach,” we provide an approach to teaching the concept of
auto-PEEP to senior residents and fellows working in the intensive care unit. We offer a
framework for educators to effectively present the concepts of auto-PEEP to learners,
either at the bedside or in the classroom setting, by summarizing key concepts and
including concrete examples of the educational techniques we use. This framework
includes specific content we emphasize, how to present this content using a variety of
educational resources, assessing learner understanding, and how to modify the topic on
the basis of location, time, or resource constraints.

The traditional approach to teaching concepts of mechanical ventilation

mechanical ventilation often begins with a incorporate complex physiological
basic description of the various ventilator principles. Although educators may
modes, their associated settings, and possess an intuitive understanding of such
proper adjustment of settings to achieve principles, effectively conveying these
adequate oxygenation and ventilation. complex topics to a learner can be
Although these aspects are universally difficult. This is often the case when
taught to trainees in the intensive care confronted with the task of explaining
unit (ICU), more advanced concepts are auto-positive end-expiratory pressure
often eschewed. Some fundamental (auto-PEEP). Auto-PEEP is a common

This article is open access and distributed under the terms of the Creative Commons Attribution
Non-Commercial No Derivatives License 4.0. For commercial usage and reprints, please e-mail
Diane Gern.
Correspondence and requests for reprints should be addressed to Burton W. Lee, M.D.,
Department of Critical Care Medicine, National Institutes of Health, 10 Center Drive,
2C145 Bethesda, MD 20892. E-mail: [email protected].
This article has a data supplement, which is accessible from this issue’s table of contents at
www.atsjournals.org.
Copyright © 2022 by the American Thoracic Society
DOI: 10.34197/ats-scholar.2022-0024HT

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HOW I TEACH

and frequently underrecognized problem on the educational context, such as the

in the ICU that can have serious clinical learners’ degree of training or time con-
consequences (1). All clinicians managing straints, all or just a few of the most rele-
a mechanically ventilated patient should vant questions may be used. We typically
be familiar with preventing, identifying, begin with a simple question when discus-
and treating auto-PEEP. sing auto-PEEP: “For a relaxed, passively
What makes auto-PEEP difficult to teach? exhaling patient, what determines how
First, trainees may not be familiar with long it takes for the patient to fully expire
the physiological factors that dictate expi- the inspired tidal volume?”
ratory airflow. Learners may also lack Answering this question involves
familiarity with the interpretation of venti- introducing the basic elements that dictate
lator scalar waveforms, including normal expiratory airflow. We start with the
waveforms. In addition, effectively present- principle of Ohm’s law. The hydraulic
ing complex topics can prove challenging, analogy of Ohm’s law states that:
especially under the time constraints fre- Pressure Difference ðDPÞ 5 Flow ðFÞ 3 Resistance ðRÞ,
quently encountered in the busy ICU and thus,
environment. Lastly, there is often diffi- F 5 DP = R:
culty conveying the clinical relevance of We typically make this physiologic concept
physiological concepts thought to be more intuitively accessible by drawing two
purely academic in nature. balloons connected via a tube and asking the
This entry of “How I Teach” provides an learners, “What would make the air flow
overview of our approach to teaching the from one balloon to the other?” We then
concept of auto-PEEP to senior residents label each balloon with either “P1” or “P2”
and fellows working in the ICU. We offer to indicate the pressures that compose the
a framework for educators to effectively pressure gradient for flow and draw an
present the concepts of auto-PEEP to arrow across the tube from the balloon with
these learners, either at the bedside or in higher pressure to the balloon with lower
the classroom setting. We summarize the pressure to indicate the direction of flow. We
key concepts and include concrete exam- then label the tube with an “R” to indicate
ples of the educational techniques we use resistance and display the completed Ohm’s
to convey the concept of auto-PEEP in a law equation next to the figure. We may also
practical manner. ask, “If there is little flow between the
balloons, what may be inferred about
PRESENTING THE TOPIC the pressures in the two balloons or about
We approach the teaching of complex the resistance of the tubing?” to help learners
topics in mechanical ventilation by first understand that a lack of flow can be seen
partitioning them into smaller sections and when there is no longer a pressure gradient
by asking learners a series of manageable or in the setting of high resistance.
questions that explore critical elements of It is often helpful to designate one of the
the subject matter. This approach balloons as representing the alveoli. In this
encourages learner involvement, provides case, one balloon would be labeled Palv,
the proper context for the topic, and and the other balloon as a compartment
offers the educator a basic framework for representing the proximal airway pressure
presenting the subject in a logical, well- near the ventilator during expiration
organized manner (Table 1). Depending labeled as PEEP (Figure 1). Thus,

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Table 1. Question-based format for teaching auto-PEEP

Eight Questions We Ask Learners Examples of How We Teach

1. For a relaxed patient passively expiring, Volume–time scalar (Video E1 and

what determines how long it takes for Figures 3A and 3B)
the patient to fully expire the inspired
tidal volume?

2. What happens when a breath is initiated Thought exercise in which the learner takes
before a patient has completely expired breaths, noting the position of the
the previous breath? diaphragm with complete vs. incomplete
exhalation

3. What are the consequences of auto- Video E1

PEEP?

4. What factors determine how much of an Explanation of the natural decay equation
inspired volume (and therefore pressure)
remains in the lung at the end of
expiration?

5. How do we estimate the time required Illustrations (Figure 3A), Videos E1 and E2
for a patient to expire without
developing auto-PEEP?

6. How do we estimate the expiratory time Bedside demonstrations (Videos E1 and E2)
constant (t)?

7. What are the signs of auto-PEEP on the Bedside demonstrations and illustrations
ventilator? (Figure 4)

8. How can we address auto-PEEP? Video E1 and Figure 2

Definition of abbreviation: PEEP = positive end-expiratory pressure.

expiratory flow is determined not only by “How would pressure in the balloon
the magnitude of the pressure gradient change if the balloon was ‘stiffer’ or
between the patient’s alveolar pressure ‘floppier’?” are helpful to guide the
(Palv) and the ventilator’s pressure at discussion. Encouraging group
expiration (PEEP) but also by the participation and gauging the responses to
resistance of the respiratory system, the aforementioned questions can help
including that of the ventilator tubing. inform the teacher as to when they can
We then introduce the concept of move on to the subsequent topics. This is
compliance by asking, “What determines particularly important because learners
the pressure in a given balloon?” Because may struggle with the ensuing topics if
compliance (C) is the ratio of the change they cannot adequately articulate the key
in volume (DV) per change in pressure physiologic concepts presented thus far. If
(DP), or C 5 DV = DP, the learners can learners appear to be struggling with these
typically deduce, especially with some concepts, it may be best to defer
guidance, that pressure will be higher with introducing the natural decay equation in
larger tidal volumes or with lower subsequent sections and simply focus on
compliance. Often, questions such as the clinical consequences and
“What would happen to pressure in the identification of auto-PEEP at the bedside
balloon as it fills with more volume?” or presented later in this article. One can

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Figure 1. Illustration of the pressure–time, flow–time, and volume–time scalars with a focus on expiration.
We emphasize to the learner that, at the onset of expiration, the pressure gradient will be largest and
expiratory flow will be at its peak value. As air flows out of the alveoli, alveolar volume and pressure (and
therefore flow) will gradually decline in an exponential fashion until alveolar pressure equals the
downstream pressure (set PEEP), at which point the flow will cease. The dotted line represents alveolar
pressure throughout the respiratory cycle, which is only measurable when the flow is paused. PEEP = positive
end-expiratory pressure.

return to these concepts at a later date, as factors, in turn, contributing to the

some learners feel more comfortable with alveolar pressure. We reinforce these
this content once they have spent time in concepts by comparing volume–time sca-
the ICU environment and gained addi- lars on the ventilator for patients with dif-
tional clinical context for these abstract ferent respiratory system resistances and
examples. compliances. For example, when possible,
At this point, the learner should be able we compare a volume–time scalar from a
to identify the three key factors that patient with chronic obstructive pulmo-
determine the time it takes for a patient to nary disease (COPD) (high R and high C)
fully expire a tidal volume: 1) the size of to a scalar from a patient with acute respi-
the tidal volume; 2) the compliance of the ratory distress syndrome (ARDS) (low C)
respiratory system; and 3) the resistance of at the bedside. Because real patients are
the respiratory system, with the first two not readily available in a classroom

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setting, we compare volume–time scalars that auto-PEEP must be considered in any

using a test lung with capacity for variable hemodynamically unstable, mechanically
resistance and compliance to simulate dif- ventilated patient. We find that auto-
ferent disease states. PEEP is an often overlooked cause of
With the factors that dictate expiratory hypotension; however, the mechanism of
flow firmly in hand, we can now transition hypotension in patients with auto-PEEP is
more directly into the topic of auto-PEEP. relatively well understood by learners with
To practically define auto-PEEP, we next some guidance. We explain that hypoten-
ask, “What happens when a breath is initi- sion because of auto-PEEP results from
ated before a patient has completely several potential mechanisms, including
expired the previous breath?” decreased venous return because of
increases in intrapleural pressure.
Although this concept may be intuitive for
Increases in intrapleural pressure decrease
some learners, it allows us to introduce
the pressure gradient for venous return to
and further refine our definitions of
the thorax. We may illustrate this concept
various types of PEEPs. We begin with
by drawing two compartments side by
the concept that any inspired volume that
side and labeling one as “thorax” and the
is not fully exhaled remains in the lung at
other as “abdomen,” with an arrow flow-
the beginning of the next breath. Any of
ing from the abdomen to the thorax to
this excess volume results in additional
signify venous inflow. This also provides
pressure above the set PEEP that is
an opportunity to reinforce Ohm’s law
programmed into the ventilator (PEEPset).
using a slightly different context. We may
This additional pressure above PEEPset is
further explain that, as the lungs hyperin-
auto-PEEP (also referred to as intrinsic
flate, the increase in lung volume causes
PEEP). The sum of PEEPset and auto-
compression of perialveolar vessels result-
PEEP represents the total PEEP (PEEPto-
ing in an increase in pulmonary vascular
tal). As a thought exercise at the bedside,
resistance and afterload of the right ventri-
we ask our learners to take a breath, par-
cle (2). These physiologic derangements
tially exhale the volume in their lungs,
may decrease cardiac output and result in
and then take a subsequent breath. We
hypotension. We also note that alveolar
ask the learner to consider the position of
overdistention can cause direct compres-
the diaphragm with each breath as a
sion of the alveolar capillaries and, in con-
result of air trapping.
junction with a reduction in cardiac
With a practical definition of auto-PEEP output, result in increased dead space (3).
in hand, we introduce the clinical conse- This increase in dead space can further
quences of auto-PEEP by asking, “What cause respiratory acidosis, which may
are the clinical consequences of impair cardiac function. In a classroom
auto-PEEP?” setting, we typically set up a test lung with
We emphasize that the four main clinical the capacity for variable resistance and
consequences of auto-PEEP are hypoten- compliance to illustrate the life-threatening
sion, ventilator-induced lung injury, implications of auto-PEEP. Using a high
patient–ventilator asynchrony, and resistance and high compliance test lung
increased dead space. We write down the system to mimic a patient with COPD, we
responses to this question and, if time per- can easily illustrate air trapping, thereby
mits, go into further detail into the mecha- demonstrating the potential for lung over-
nisms of each. Our teaching underscores distention. Furthermore, by asking

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learners to imagine the status of the heart increasing the PEEPset may reduce the
situated between such overdistended lungs, threshold load required to trigger a
the clinical implications of decreased breath. We then describe how this addi-
venous return from increased intrapleural tional pressure results in an increase in the
pressures become more readily apparent. patient’s work of breathing, as well as
We also stress that auto-PEEP may have potential patient discomfort and agitation.
different consequences on mechanical ven- For an additional example of how we
tilation depending on the mode of ventila- teach ineffective triggering to our learners,
tion. In volume-controlled ventilation, the the reader is referred to a previously pro-
progressive accumulation of auto-PEEP duced video (4). A frequently asked ques-
may cause alveolar overdistention and tion is whether or not this concept applies
ventilator-induced lung injury. In to a flow-triggering mechanism. Because a
pressure-controlled ventilation, auto-PEEP patient must lower airway pressure below
decreases the pressure gradient for inspira- PEEPset to generate flow, this mechanism
tory flow (airway pressure 2 PEEPtotal), of ineffective triggering still applies.
resulting in lower tidal volumes and hypo- Now that the potentially dangerous
ventilation. This is easily illustrated at the consequences of auto-PEEP have been
bedside or in the classroom setting by emphasized, to identify and treat auto-
drawing the two-compartment model with PEEP, we must familiarize our learners
a ventilator on one side and a balloon with the factors that determine if a patient
(lung) on the other attached by a tube (air- is at risk. Our next question is, “What fac-
way) (similar to Figure 1). In volume con- tors determine how much of an inspired
trol, we illustrate increasing amounts of volume (and therefore pressure) remains in
volume progressively filling the balloon the lung at the end of expiration?”
with each successive breath. For pressure We begin by acknowledging that, in a
control, we illustrate accumulating pres- passively exhaling patient, alveolar volume
sure above PEEPset reducing the pressure (and pressure) will gradually decline in a
gradient for airflow at the start of each characteristically exponential fashion. At
breath, thereby resulting in progressively this juncture, we introduce the equation
lower tidal volumes with each successive that governs this exponential decline, the
breath. natural decay equation,
We find that ineffective triggering, a form Vi 5 Vo =et=RC ,
of patient–ventilator asynchrony frequently
precipitated by auto-PEEP, is often a diffi- whereby Vi is the volume remaining in
cult concept for learners to grasp. Our the lung at time i during expiration, Vo is
approach is to draw a diagram that identi- the initial volume delivered to the alveoli
fies the patient’s degree of auto-PEEP, the (i.e., tidal volume), t is the amount of time
PEEPset, and the pressure below the available for expiration, C is the
PEEPset that the airway pressure must compliance of the respiratory system, R is
reach to trigger the ventilator (Figure 2). the total resistance of the respiratory
This demonstration allows for a visual rep- system, and e is a mathematical constant
resentation of the additional pressure that at the base of the natural logarithm and is
must be overcome as a result of auto- equal to 2.718.
PEEP to trigger a breath. This depiction At first glance, most learners find this
also allows learners to visualize how equation to be somewhat daunting. As a

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Figure 2. Illustration depicting how auto-PEEP may cause ineffective triggering. In the figure on the left, the
trigger threshold is set at 2 cm H2O below PEEPset. Because the PEEPset is 5 cm H2O, this patient would have
to lower alveolar pressure to 3 cm H2O to trigger a breath. Because this patient has developed 7 cm H2O of
auto-PEEP above the PEEPset of 5 cm H2O (i.e., PEEPtotal of 12 cm H2O), the patient would have to generate
at least 29 cm H2O to lower the alveolar pressure to 3 cm H20. In the figure on the right, the PEEPset has
been raised to 10 cm H20 for the same patient. The trigger threshold is still set to 2 cm H2O below the
PEEPset of 10 cm H20 (i.e., 8 cm H2O). Now the patient would only have to generate negative 4 cm H2O (i.e.,
from 12 to 8 cm H2O) to lower the alveolar pressure below the trigger threshold. auto-PEEP = auto-positive
end-expiratory pressure; PEEPset = PEEP set on ventilator; PEEPtotal = Total PEEP.

result, we typically do not engage all therefore, what an appropriate respiratory

learners with this equation. However, for rate is to avoid auto-PEEP? We now
fellows and other learners who want to introduce the very important concept of
master the concept of auto-PEEP, an time constants and tau (t) by asking,
explanation of each variable in the equa- “How do we estimate the time required
tion provides significant clarity and allows for a patient to expire without developing
learners to recognize the clinical applica- auto-PEEP?”
tions of this equation. Each variable on As we just explained to the learners, the
the right represents a factor that contrib- natural decay equation contains the
utes to the development of auto-PEEP. product of respiratory system resistance
We typically circle or highlight each one and compliance (R 3 C). The product of
as they are explained. Starting with Vo, R and C is referred to as the expiratory
we note that a larger initial volume deliv- time constant and is represented by the
ered to the alveoli (i.e., tidal volume) will Greek letter tau (t). The natural decay
result in a larger amount of air remaining equation above can now be rewritten as:
in the alveoli at any point in time during Vi 5 Vo = et=t :
expiration (Vi). Thus, one risk factor for
It is important for the learners to grasp
the development of auto-PEEP is a large
that the expiratory time constant (t)
tidal volume. Next, we stress that expira-
represents the time required for the lungs
tory time (t) is inversely proportional to
to exhale until only approximately 37% of
Vi. Thus, another risk factor for the devel-
the initial volume remains in the lungs (5).
opment of auto-PEEP is a short expiratory
We often start by illustrating this
time. Finally, we point out that the respi-
important concept by drawing a graph
ratory system resistance and compliance depicting the decay in volume over time
change in parallel to Vi, and therefore, (Figure 3A). We label the y-axis as volume
high R and C are also risk factors for the (tidal volume in this case), the x-axis as
development of auto-PEEP. time, and then draw a typical decay
How can we further use concepts from pattern noting that one t represents the
this equation to determine how much time point at which 37% of the initial
time a given patient needs to expire and, volume remains in the lungs. For further

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A B

Figure 3. (A) Illustration of the decline in tidal volume over time during expiration. The period of time
required for volume to decrease to 37% of its initial value is equivalent to one time constant. Each additional
time constant represents another 63% reduction in volume from the previous value. We emphasize that,
clinically, a patient should have an exhalation time greater than at least three time constants to adequately
exhale the tidal volume, as indicated by the arrow, representing a reduction to less than 5% of the initial
tidal volume. (B) Illustration of two patients with different time constants (tau). We emphasize to the learner
how the patient with the longer tau will require a longer expiratory time to exhale a given volume.

clarification, we may demonstrate that by COPD]) will require more time to exhale
setting t equal to expiratory time (t) in the than patients with a short t (low C [i.e.,
natural decay equation, Vi always equals ARDS]). We often use the analogy of a
Vo / e, which is 37% of Vo, as 1 / e is long t represented by a grocery bag pas-
approximately equal to 0.37. We then sively emptying into a tube with a small
show that each additional time constant diameter versus a short t represented by a
represents a further 63% reduction of the stretched rubber tire emptying into a tube
previous value such that after two time with a large diameter (Figure 3B). In the
constants, 14% of the initial tidal volume classroom setting, to assess learners’
will remain in the lungs (37% of 37%), understanding at this juncture before
and after three time constants, 5% of the moving on to the next topic, we have the
initial tidal volume will remain in the learners break into groups and have them
lungs during expiration (37% of 14%), and write out the natural decay equation and
so on (Figure 3A). Therefore, patients then reproduce a graph of the decay of
need longer than three time constants to volume over time during expiration.
appropriately exhale the tidal volume Although a whiteboard may not be readily
before initiating the next breath. This is a available in some ICUs, this exercise can
key concept, and we often reemphasize it still be done on a piece of paper with the
by asking the learners, “How much time learners huddled around the instructor.
should we ensure the patient has to Some learners may not immediately grasp
adequately exhale on the ventilator?” In the mathematical underpinnings of the
other words, to minimize auto-PEEP, we time constant. If this is the case, it is often
must ensure that the patient’s expiratory helpful to simply emphasize the general
time (t) is greater than at least 3 t. concept that a patient will require at least
Patients with a long t (high R and C [i.e., 3 t to adequately exhale and that by

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calculating t, we now know how much calculate R and C are obtained during
time a patient needs to adequately exhale. inspiration and, as a result, represent the
Most learners will feel comfortable with inspiratory time constant. If the airway
resistance is higher during expiration than
this concept and move forward with how
inspiration, this approach may underesti-
we calculate t in the ensuing sessions. mate the time constant (7). This exercise
As previously mentioned, if we know t, can also incorporate the process of calcu-
we can therefore determine whether a lating respiratory system resistance and
patient’s respiratory rate puts them at risk compliance at the bedside, a valuable
opportunity to expand on respiratory sys-
for auto-PEEP. We now have provided
tem physiology.
our learners with a deep understanding of 2. Evaluating the volumes. A particularly
the physiology behind the development of valuable exercise for learners is to esti-
auto-PEEP. We can now transition back mate the expiratory t by examining the
to the clinical basis of what we have dis- volume–time scalar on the ventilator and
cussed: “How do we estimate the expira- noting the amount of time required for a
given volume to decrease to approxi-
tory time constant (t)?”
mately 37% of its value. This will require
We emphasize the importance of routinely freezing the ventilator display and placing
calculating t in critically ill, mechanically two markers on the volume–time scalar
ventilated patients to guide our mechanical that represents the initial chosen volume
ventilation settings (respiratory rate, (Vo) followed by a point at 37% of this ini-
tial value. The time period between these
inspiratory flow pattern and rate, and tidal
two markers represents 1 t. (Video E1 in
volume). There are several strategies that the data supplement reviews this
can be employed at the bedside. We approach to assessing t and provides an
typically teach the following three methods: example of the way in which we typically
assess a learner’s understanding of this
1. Measure respiratory system resistance and
method.) Note that the initial volume (Vo)
compliance during a square wave flow,
should ideally be recorded after the initial
volume control breath (6). As stated earlier,
rapid deflection of the expiratory flow
the product of R and C is t:
time curve because the interpretation of
t 5 R ðcm H2 O=L=sÞ 3 C ðL=cm H2 OÞ: the initial portion of this curve is con-
founded by interference of inertial effects,
It is often helpful to write out this equation rapid opening of the expiratory valve, and
for the learners to notice that multiplying potential patient effort (8). In our experi-
the units of R and C leaves units of sec- ence, this method is the easiest for the
onds, hence, the name time constant. This learner to comprehend as it provides a
value is the time constant (t) of the patient simple visual representation of natural
and allows us to estimate the time required
decay and can be performed readily at
for exhalation. We then provide a simple
the bedside.
example: a patient with a C of 0.1 L/cm
3. Volume to flow ratio (V/F) approach.
H20 and R of 10 cm H20/L/s has a calcu-
Another method for estimating t that is
lated t of 1 second and will require more
helpful to demonstrate at the bedside in-
than 3 seconds (.3 t) to adequately exhale
volves dividing the remaining volume (V) by
the given tidal volume. If we assume an
the exhaled flow rate (F) at the same time
inspiratory time of 1 second, this patient
point (9):
should not develop significant auto-PEEP
if the total respiratory rate is less than 15 V = F 5 RC 5 t:
breaths per minute because the breath-to-
breath time is at least 4 seconds. One We typically encourage our fellows and
caveat to inform learners of when using other learners who want to master the
this method is that the values used to concept of auto-PEEP to derive this

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from the equation of motion (Index patterns suggestive of auto-PEEP worthy

Page E1) as it not only explains t but of pointing out. We focus on the following
also a number of other important phys- four patterns, which are best presented on
iologic concepts. Calculations of t at the ventilator at the bedside but can also
multiple time points can be made, all be displayed as figures in a classroom set-
of which should be similar because the ting as well.
slope of the flow–volume curve in a 1. Asymmetry in the areas of the flow–time
passive patient should be linear (10). curves. We teach that “what goes in should
(Video E2 reviews the volume/flow come out.” We first direct the learner’s atten-
method, as well as the ways in which tion to the flow–time scalar at the bedside (or
we assess a learner’s understanding of with a pictorial in the classroom setting) and
start by asking, “What does the area under
this concept.)
the flow–time curve represent?” We explain
To further assess understanding, we will that the area under the flow–time curve dur-
have trainees calculate t at the bedside ing inspiration represents inhaled tidal vol-
(either on rounds or bedside teaching ume; during expiration, this area represents
exhaled volume. This may be further illus-
sessions). We find that the volume/flow
trated by drawing a tube attached to a bal-
method is the most difficult for learners to loon with an arrow indicating air flowing
grasp. However, with practice, it becomes into the balloon and asking, “If we capture
one of the most time-efficient ways of cal- all of the air flowing into the balloon over a
culating t. If a learner is having difficulty certain time period, what does the volume in
with the volume/flow method, it is accept- the balloon represent?” We may then ask,
“What if the area under the expiratory
able to move on to subsequent topics and
flow–time curve is less than the area under
return to this concept another time, espe- the inspiratory flow–time curve?” It should
cially given that the “evaluating the vol- then become obvious that if a patient is
umes” method above is typically more completely expiring the tidal volume just
intuitively understood. inspired, the area under these curves should
be approximately equal in size (11). If the
By teaching these three methods, we expiratory area is consistently smaller than
emphasize the importance of calculating t the inspiratory area, this suggests that the
and acknowledging the expiratory time of patient is not able to exhale fully and, thus, is
the patient to help prevent the onset of vulnerable to developing auto-PEEP (Figure
auto-PEEP. Continuing with the bedside 4A). Importantly, we remind learners that,
whereas unequal areas under the curves
application of what we have learned, we
may also occur in the setting of an air leak,
now focus on how to identify the presence typically the expiratory flow will return to
of auto-PEEP. We now ask, “What are zero in this setting as pressure is rapidly dissi-
some signs of auto-PEEP on the ventilator?” pated from the lungs.
2. Persistent end-expiratory flow. We start off
The trainee should recognize that auto-
teaching this concept by directing the learn-
PEEP must be considered in mechanically er’s attention to the expiratory flow–time
ventilated patients who have unexplained curve and asking, “If flow returns to zero,
hypotension, difficulty triggering a breath, what does this imply?” This reintroduces
or agitation. On the basis of the discussion the concept of Ohm’s law presented earlier,
above, they should also recognize patients which may require asking the learners to
write out the equation again. This will
at increased risk (i.e., patients with high
allow the learners to understand that if all
respiratory rates, short expiratory times, of the inspired tidal volume has been
and/or obstructive airway disease). There exhaled, the pressure in the alveoli (Palv)
are also several ventilator waveform should now equal PEEPset. Because the

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A B

C D

Figure 4. Signs of auto-PEEP. (A) Unequal areas under the curve. The area under the inspiratory flow–time
scalar is larger than the expiratory flow–time scalar, indicating that not all volume has been exhaled from
the lungs. (B) Persistent end-expiratory flow, signifying a persistent pressure gradient between alveolar
pressure and PEEPset because of auto-PEEP. (C) The end-expiratory hold maneuver. The dotted line repre-
sents alveolar pressure throughout the respiratory cycle (which is only able to be measured when the flow is
paused). (D) Ineffective triggering. In this example, the patient is unable to lower alveolar pressure below
the threshold for triggering because of significant auto-PEEP. auto-PEEP = auto-positive end-expiratory
pressure; PEEPset = PEEP set on ventilator.

pressures are equal, there is no longer a should now realize that if the flow is still
pressure gradient, and flow should be zero present at the end of expiration, there is still
(Figure 4B). We then ask the learner, “If pressure in the alveoli above PEEPset that is
there is still flow present at the end of expi- driving flow out of the lungs. This addi-
ration, what does this imply?” Learners tional pressure is auto-PEEP. Once again,

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incorporating the two-compartment model, the learners as deflections on the flow–time

as previously discussed, is very helpful in scalar representing patient respiratory mus-
illustrating this concept. cle efforts that fail to trigger mechanical
3. Measurement via an end-expiratory pause. breaths. In addition to pointing this out on
An important (and often misunderstood) the flow–time scalar, it is helpful to once
concept for learners to understand is that again draw the pressure–time scalar and
the pressure–time waveform will display superimpose the changes in alveolar pres-
PEEPset (determined by the clinician) sure occurring with an ineffective trigger
throughout expiration. Palv, which gradu- during expiration (Figure 4D). To further
ally declines as volume is exhaled, is not assess learners’ understanding, asking the
directly depicted on the display. We find it learner about the other causes of ineffective
helpful to draw a sample pressure–time triggering is often helpful. With a little addi-
scalar during expiration with airway pres- tional guidance, they should realize that a
sure as PEEPset (a straight line) and super- patient with neuromuscular weakness may
impose the alveolar pressure–time curve not have adequate strength to trigger a
with an exponential decay in the back- breath or that a trigger sensitivity threshold
ground. Now we emphasize that with an that is set too high may make it more diffi-
end-expiratory pause maneuver, the expi- cult for a patient to trigger a breath. How-
ratory valve closes, and flow stops. This ever, the learner should understand that,
allows the Palv to equilibrate with the air- whereas neuromuscular weakness and an
way pressure; as a result, the pressure–time insensitive trigger setting may also result in
scalar will now reflect the Palv (Figure 4C). ineffective triggers, auto-PEEP is by far the
This measured Palv at the end of expiration most common cause (14).
is the total PEEP (PEEPtotal). The amount
of pressure present above the PEEPset is Now that our learners are adept at
the amount of auto-PEEP present: understanding how to prevent and identify
PEEPtotal 2 PEEPset 5 auto2PEEP:
auto-PEEP, we turn to asking, “How can
we address auto-PEEP?”
Educators should communicate a few limita-
tions to this measurement. First, the patient We begin by teaching that in the event of
must be passive throughout this maneuver acute hemodynamic instability, the patient
so that patient effort does not alter the value. may momentarily be disconnected from the
Second, only lung units in communication ventilator to allow for a full exhalation.
with the airway will equilibrate with the air- However, we stress that strategies to
way pressure. In the setting of airway clo-
prevent the development and recurrence of
sure, some lung units will not be in
communication with the airway, and thus,
auto-PEEP must then be considered.
auto-PEEP may be underestimated (12). (Video E3 provides an example of how we
4. Ineffective triggering. As described above, assess a learner’s understanding of the clini-
auto-PEEP can make it more difficult for cal consequences of autoPEEP and the
a patient to trigger the ventilator, as ways in which to manage auto-PEEP.)
increased negative pressure must be gener-
ated to overcome the intrinsic PEEP. This To solidify the physiological and
may impair the patient’s ability to trigger a mathematical underpinnings of this
mechanical breath, a phenomenon known complex topic, we refer back to the
as ineffective triggering (13). It may be help- equation of natural decay, highlighting
ful to begin by asking learners to recall how and explaining how each variable can be
the patient triggers a mechanical breath on examined and addressed when
the ventilator and reemphasizing that the
approaching our treatment of auto-PEEP.
patient must generate an appropriate
amount of inspiratory muscle effort to over- This allows the learner to feel comfortable
come the clinician-set pressure or flow trig- with the equation and demonstrate its
gers. Ineffective triggers can be shown to practicality, especially in the ICU setting.

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Therefore, we first ask the learners to We often teach the concept that to
write out the equation of natural decay. improve patient work of breathing and
We then emphasize that according to this ineffective triggering, the PEEPset may be
equation, we can reduce the amount of increased to a point just below the
volume remaining in the alveoli at the end PEEPtotal (16). Because the patient only
of expiration (Vi) and therefore reduce needs to lower the airway pressure below
auto-PEEP by decreasing the delivered PEEPset to trigger the ventilator, this
tidal volume (Vo), increasing exhalation maneuver will decrease the amount of
time (t), and decreasing t. For emphasis
auto-PEEP the patient must overcome to
and clarity, we typically circle each vari-
trigger the breath. Our approach usually
able in the equation as we name them
involves illustrating this concept by draw-
individually, and we stress that increasing
ing pressure–time scalars with superim-
the expiratory time is best achieved by
posed alveolar pressure–time curves, as
lowering the respiratory rate. This may
demonstrated in Figure 2. Alternatively,
involve sedating and/or paralyzing the
patient if the patient’s intrinsic respiratory we use a more interactive approach using
rate is higher than the set rate on the ven- the different heights of two participants,
tilator. We often teach this concept by as demonstrated in a previously recorded
drawing a table and asking learners to fill video (4), to demonstrate that the differ-
in the breath-to-breath time, the inspira- ence between the end-expiratory alveolar
tory time, and the expiratory time for var- pressure and PEEPset increases the effort
ious respiratory rates (a sample of such required to trigger a breath. This teaching
tables is given in the Index Page E2). strategy also helps to illustrate that
Trainees often note that increasing the set decreasing this difference by increasing
inspiratory flow rate will decrease inspira- the PEEPset may make it easier to trigger
tory time as the set tidal volume must the breath. Two considerations should be
now be delivered more rapidly. However, made when teaching this latter point to
this strategy will generally only increase learners. First, increasing the PEEPset
exhalation time by fractions of a second, should not increase the PEEPtotal as long
whereas lowering the respiratory rate will as it remains below PEEPtotal (17). In
provide much larger increases in expira-
order for air to flow from the ventilator to
tory time (Index Page E2). Educators
the patient, the pressure in the airway
should also emphasize that although low-
must be higher than the pressure in
ering tidal volume may appear to be an
the alveoli. If PEEPset remains below
effective strategy to minimize auto-PEEP,
PEEPtotal, the gradient for airflow remains
this strategy may be met by a compensa-
from the patient toward the ventilator.
tory increase in the patient’s intrinsic
respiratory rate, which may ultimately Second, a common misconception is that
decrease the expiratory time (15). Lastly, this strategy is a treatment for auto-PEEP;
we ask the learners to recall that t is the instructors must reinforce that this man-
product of R and C and that minimizing agement strategy merely corrects ineffec-
the R through the use of interventions tive triggering. In fact, by allowing the
such as bronchodilators, corticosteroids, patient to trigger the ventilator more fre-
and suctioning of secretions will allow for quently, one may theoretically worsen the
more rapid exhalation. auto-PEEP.

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HOW I TEACH

MODIFYING THE FRAMEWORK quick demonstration of the calculation of

The concepts above can be presented in a t at the bedside, followed by titration of
classroom setting, during bedside teaching ventilator settings. In this instance, though
sessions, or on ICU rounds. However, they may be briefly mentioned, the specif-
teaching this material using this ics regarding the clinical consequences of
framework may require modifications auto-PEEP or identification of auto-PEEP
depending on the location, context, or on the ventilator scalars may be best pre-
constraints of time or resources available. sented at another time (or vice versa). In
In a classroom setting with a ventilator our experience, each component of the
and a test lung capable of variable R and topic of auto-PEEP presented above has
C, a thorough presentation of the topic proved quite valuable, even if the topic
typically takes about an hour. If a test cannot be presented in totality.
lung or ventilator is not available, it may
be necessary to provide screenshots of CONCLUSIONS
sample ventilator scalar waveforms or
Teaching the principles of mechanical
illustrate them on a whiteboard. We
ventilation involves incorporating a unique
have also used an interactive, online
and exciting blend of cardiopulmonary
mechanical ventilation simulator when
mechanical ventilators are unavailable or physiology and clinical application. This
when teaching virtually (available with can be an incredibly rewarding yet
permission at https://iculearning.com/). challenging task. In this article, we
Other similar mechanical ventilation simu- provide our framework for teaching the
lators are available in an open-access often overlooked principle of auto-PEEP.
format (18). The approaches we provide can be used
Given the time constraints of the ICU, it at the bedside or in a classroom setting. In
is often necessary to divide the material addition, given the time constraints often
and focus on specific aspects in any given associated with bedside teaching, several
session. For instance, when faced on of the sections presented above may be
rounds with a patient with severe effectively presented independently, with
obstructive lung disease, it may be some brief context. Most importantly,
worthwhile to focus on how the team may effective teaching of these concepts
approach ventilator settings. In this case, requires practice and continued refine-
spending 5–10 minutes on introducing the ment on the educator’s part. We hope
natural decay equation and t may be time that this framework provides a cogent
well spent. This may be followed by a guide for teaching this complex topic.

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