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Wu M, Yuan X, Liu L, Yang Y. Neurally Adjusted Ventilatory Assist vs. Conventional Mechanical Ventilation in Adults and Children With Acute Respiratory Failure: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2022; 9:814245. [PMID: 35273975 PMCID: PMC8901502 DOI: 10.3389/fmed.2022.814245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 01/20/2022] [Indexed: 11/13/2022] Open
Abstract
Background Patient-ventilator asynchrony is a common problem in mechanical ventilation (MV), resulting in increased complications of MV. Despite there being some pieces of evidence for the efficacy of improving the synchronization of neurally adjusted ventilatory assist (NAVA), controversy over its physiological and clinical outcomes remain. Herein, we conducted a systematic review and meta-analysis to determine the relative impact of NAVA or conventional mechanical ventilation (CMV) modes on the important outcomes of adults and children with acute respiratory failure (ARF). Methods Qualified studies were searched in PubMed, EMBASE, Medline, Web of Science, Cochrane Library, and additional quality evaluations up to October 5, 2021. The primary outcome was asynchrony index (AI); secondary outcomes contained the duration of MV, intensive care unit (ICU) mortality, the incidence rate of ventilator-associated pneumonia, pH, and Partial Pressure of Carbon Dioxide in Arterial Blood (PaCO2). A statistical heterogeneity for the outcomes was assessed using the I 2 test. A data analysis of outcomes using odds ratio (OR) for ICU mortality and ventilator-associated pneumonia incidence and mean difference (MD) for AI, duration of MV, pH, and PaCO2, with 95% confidence interval (CI), was expressed. Results Eighteen eligible studies (n = 926 patients) were eventually enrolled. For the primary outcome, NAVA may reduce the AI (MD = -18.31; 95% CI, -24.38 to -12.25; p < 0.001). For the secondary outcomes, the duration of MV in the NAVA mode was 2.64 days lower than other CMVs (MD = -2.64; 95% CI, -4.88 to -0.41; P = 0.02), and NAVA may decrease the ICU mortality (OR =0.60; 95% CI, 0.42 to 0.86; P = 0.006). There was no statistically significant difference in the incidence of ventilator-associated pneumonia, pH, and PaCO2 between NAVA and other MV modes. Conclusions Our study suggests that NAVA ameliorates the synchronization of patient-ventilator and improves the important clinical outcomes of patients with ARF compared with CMV modes.
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Affiliation(s)
- Mengfan Wu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Xueyan Yuan
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Ling Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
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Zhou C, Chase JG, Sun Q, Knopp J, Tawhai MH, Desaive T, Möller K, Shaw GM, Chiew YS, Benyo B. Reconstructing asynchrony for mechanical ventilation using a hysteresis loop virtual patient model. Biomed Eng Online 2022; 21:16. [PMID: 35255922 PMCID: PMC8900099 DOI: 10.1186/s12938-022-00986-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 02/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patient-specific lung mechanics during mechanical ventilation (MV) can be identified from measured waveforms of fully ventilated, sedated patients. However, asynchrony due to spontaneous breathing (SB) effort can be common, altering these waveforms and reducing the accuracy of identified, model-based, and patient-specific lung mechanics. METHODS Changes in patient-specific lung elastance over a pressure-volume (PV) loop, identified using hysteresis loop analysis (HLA), are used to detect the occurrence of asynchrony and identify its type and pattern. The identified HLA parameters are then combined with a nonlinear mechanics hysteresis loop model (HLM) to extract and reconstruct ventilated waveforms unaffected by asynchronous breaths. Asynchrony magnitude can then be quantified using an energy-dissipation metric, Easyn, comparing PV loop area between model-reconstructed and original, altered asynchronous breathing cycles. Performance is evaluated using both test-lung experimental data with a known ground truth and clinical data from four patients with varying levels of asynchrony. RESULTS Root mean square errors for reconstructed PV loops are within 5% for test-lung experimental data, and 10% for over 90% of clinical data. Easyn clearly matches known asynchrony magnitude for experimental data with RMS errors < 4.1%. Clinical data performance shows 57% breaths having Easyn > 50% for Patient 1 and 13% for Patient 2. Patient 3 only presents 20% breaths with Easyn > 10%. Patient 4 has Easyn = 0 for 96% breaths showing accuracy in a case without asynchrony. CONCLUSIONS Experimental test-lung validation demonstrates the method's reconstruction accuracy and generality in controlled scenarios. Clinical validation matches direct observations of asynchrony in incidence and quantifies magnitude, including cases without asynchrony, validating its robustness and potential efficacy as a clinical real-time asynchrony monitoring tool.
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Affiliation(s)
- Cong Zhou
- School of Civil Aviation & Yangtze River Delta Research Institute, Northwestern Polytechnical University, Xian, China
- Dept of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Christchurch, New Zealand
| | - J. Geoffrey Chase
- Dept of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Christchurch, New Zealand
| | - Qianhui Sun
- Dept of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Christchurch, New Zealand
| | - Jennifer Knopp
- Dept of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Christchurch, New Zealand
| | - Merryn H. Tawhai
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Thomas Desaive
- GIGA-In Silico Medicine, Institute of Physics, University of Liege, Liege, Belgium
| | - Knut Möller
- Institute for Technical Medicine, Furtwangen University, Villingen-Schwenningen, Germany
| | - Geoffrey M. Shaw
- Dept of Intensive Care, Christchurch Hospital, Christchurch, New Zealand
| | | | - Balazs Benyo
- Dept of Control Engineering and Information Technology, Budapest University of Technology and Economics, Budapest, Hungary
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The Effect of Clusters of Double Triggering and Ineffective Efforts in Critically Ill Patients. Crit Care Med 2022; 50:e619-e629. [PMID: 35120043 DOI: 10.1097/ccm.0000000000005471] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To characterize clusters of double triggering and ineffective inspiratory efforts throughout mechanical ventilation and investigate their associations with mortality and duration of ICU stay and mechanical ventilation. DESIGN Registry-based, real-world study. BACKGROUND Asynchronies during invasive mechanical ventilation can occur as isolated events or in clusters and might be related to clinical outcomes. SUBJECTS Adults requiring mechanical ventilation greater than 24 hours for whom greater than or equal to 70% of ventilator waveforms were available. INTERVENTIONS We identified clusters of double triggering and ineffective inspiratory efforts and determined their power and duration. We used Fine-Gray's competing risk model to analyze their effects on mortality and generalized linear models to analyze their effects on duration of mechanical ventilation and ICU stay. MEASUREMENTS AND MAIN RESULTS We analyzed 58,625,796 breaths from 180 patients. All patients had clusters (mean/d, 8.2 [5.4-10.6]; mean power, 54.5 [29.6-111.4]; mean duration, 20.3 min [12.2-34.9 min]). Clusters were less frequent during the first 48 hours (5.5 [2.5-10] vs 7.6 [4.4-9.9] in the remaining period [p = 0.027]). Total number of clusters/d was positively associated with the probability of being discharged alive considering the total period of mechanical ventilation (p = 0.001). Power and duration were similar in the two periods. Power was associated with the probability of being discharged dead (p = 0.03), longer mechanical ventilation (p < 0.001), and longer ICU stay (p = 0.035); cluster duration was associated with longer ICU stay (p = 0.027). CONCLUSIONS Clusters of double triggering and ineffective inspiratory efforts are common. Although higher numbers of clusters might indicate better chances of survival, clusters with greater power and duration indicate a risk of worse clinical outcomes.
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Mojoli F, Pozzi M, Orlando A, Bianchi IM, Arisi E, Iotti GA, Braschi A, Brochard L. Timing of inspiratory muscle activity detected from airway pressure and flow during pressure support ventilation: the waveform method. Crit Care 2022; 26:32. [PMID: 35094707 PMCID: PMC8802480 DOI: 10.1186/s13054-022-03895-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 01/11/2022] [Indexed: 11/10/2022] Open
Abstract
Background Whether respiratory efforts and their timing can be reliably detected during pressure support ventilation using standard ventilator waveforms is unclear. This would give the opportunity to assess and improve patient–ventilator interaction without the need of special equipment.
Methods In 16 patients under invasive pressure support ventilation, flow and pressure waveforms were obtained from proximal sensors and analyzed by three trained physicians and one resident to assess patient’s spontaneous activity. A systematic method (the waveform method) based on explicit rules was adopted. Esophageal pressure tracings were analyzed independently and used as reference. Breaths were classified as assisted or auto-triggered, double-triggered or ineffective. For assisted breaths, trigger delay, early and late cycling (minor asynchronies) were diagnosed. The percentage of breaths with major asynchronies (asynchrony index) and total asynchrony time were computed. Results Out of 4426 analyzed breaths, 94.1% (70.4–99.4) were assisted, 0.0% (0.0–0.2) auto-triggered and 5.8% (0.4–29.6) ineffective. Asynchrony index was 5.9% (0.6–29.6). Total asynchrony time represented 22.4% (16.3–30.1) of recording time and was mainly due to minor asynchronies. Applying the waveform method resulted in an inter-operator agreement of 0.99 (0.98–0.99); 99.5% of efforts were detected on waveforms and agreement with the reference in detecting major asynchronies was 0.99 (0.98–0.99). Timing of respiratory efforts was accurately detected on waveforms: AUC for trigger delay, cycling delay and early cycling was 0.865 (0.853–0.876), 0.903 (0.892–0.914) and 0.983 (0.970–0.991), respectively. Conclusions Ventilator waveforms can be used alone to reliably assess patient’s spontaneous activity and patient–ventilator interaction provided that a systematic method is adopted. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03895-4.
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Letellier C, Lujan M, Arnal JM, Carlucci A, Chatwin M, Ergan B, Kampelmacher M, Storre JH, Hart N, Gonzalez-Bermejo J, Nava S. Patient-Ventilator Synchronization During Non-invasive Ventilation: A Pilot Study of an Automated Analysis System. FRONTIERS IN MEDICAL TECHNOLOGY 2022; 3:690442. [PMID: 35047935 PMCID: PMC8757845 DOI: 10.3389/fmedt.2021.690442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 05/28/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Patient-ventilator synchronization during non-invasive ventilation (NIV) can be assessed by visual inspection of flow and pressure waveforms but it remains time consuming and there is a large inter-rater variability, even among expert physicians. SyncSmart™ software developed by Breas Medical (Mölnycke, Sweden) provides an automatic detection and scoring of patient-ventilator asynchrony to help physicians in their daily clinical practice. This study was designed to assess performance of the automatic scoring by the SyncSmart software using expert clinicians as a reference in patient with chronic respiratory failure receiving NIV. Methods: From nine patients, 20 min data sets were analyzed automatically by SyncSmart software and reviewed by nine expert physicians who were asked to score auto-triggering (AT), double-triggering (DT), and ineffective efforts (IE). The study procedure was similar to the one commonly used for validating the automatic sleep scoring technique. For each patient, the asynchrony index was computed by automatic scoring and each expert, respectively. Considering successively each expert scoring as a reference, sensitivity, specificity, positive predictive value (PPV), κ-coefficients, and agreement were calculated. Results: The asynchrony index assessed by SynSmart was not significantly different from the one assessed by the experts (18.9 ± 17.7 vs. 12.8 ± 9.4, p = 0.19). When compared to an expert, the sensitivity and specificity provided by SyncSmart for DT, AT, and IE were significantly greater than those provided by an expert when compared to another expert. Conclusions:SyncSmart software is able to score asynchrony events within the inter-rater variability. When the breathing frequency is not too high (<24), it therefore provides a reliable assessment of patient-ventilator asynchrony; AT is over detected otherwise.
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Affiliation(s)
- Christophe Letellier
- Normandie Université - CORIA, Avenue de l'Université, Saint-Etienne du Rouvray, France
| | - Manel Lujan
- Servei de Pneumologia, Corporació Parc Taulí, Sabadell, Spain.,Departament de Medicina, Universitat Autònoma de Bellaterra, Barcelona, Spain
| | - Jean-Michel Arnal
- Service de Réanimation Polyvalente, Unité de Ventilation à domicile, Hôpital Sainte Musse, Toulon, France
| | - Annalisa Carlucci
- Pulmonary Rehabilitation, Istituti Clinici Scientifici Maugeri, Istituto di Ricovero e Cura a Carattere Scientifico, Pavia and Department of Medicine and Surgery, Respiratory Diseases, University of Insubria, Varese-Como, Italy
| | - Michelle Chatwin
- Clinical and Academic Department of Sleep and Breathing, Royal Brompton & Harefield, National Health Service Foundation Trust, London, United Kingdom
| | - Begum Ergan
- Division of Intensive Care, Department of Pulmonary and Critical Care, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Mike Kampelmacher
- Department of Pulmonology, Antwerp University Hospital and Antwerp University, Antwerp, Belgium
| | - Jan Hendrik Storre
- Department of Pneumology, University Medical Hospital, Freiburg, Germany.,Pneumologie Solln, Munich, Germany
| | - Nicholas Hart
- Lane Fox Clinical Respiratory Physiology Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Jesus Gonzalez-Bermejo
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Soins de Suites et réhabilitation respiratoire-Département R3S, Paris, France
| | - Stefano Nava
- Respiratory and Critical Care, Sant'Orsola Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), Bologna, Italy
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Saunders R, Davis JA, Bosma KJ. Proportional-assist ventilation with load-adjustable gain factors for mechanical ventilation: a cost-utility analysis. CMAJ Open 2022; 10:E126-E135. [PMID: 35168935 PMCID: PMC9259387 DOI: 10.9778/cmajo.20210078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Mechanical ventilation is an important component of patient critical care, but it adds expense to an already high-cost setting. This study evaluates the cost-utility of 2 modes of ventilation: proportional-assist ventilation with load-adjustable gain factors (PAV+ mode) versus pressure-support ventilation (PSV). METHODS We adapted a published Markov model to the Canadian hospital-payer perspective with a 1-year time horizon. The patient population modelled includes all patients receiving invasive mechanical ventilation who have completed the acute phase of ventilatory support and have entered the recovery phase. Clinical and cost inputs were informed by a structured literature review, with the comparative effectiveness of PAV+ mode estimated via pragmatic meta-analysis. Primary outcomes of interest were costs, quality-adjusted life years (QALYs) and the (incremental) cost per QALY for patients receiving mechanical ventilation. Results were reported in 2017 Canadian dollars. We conducted probabilistic and scenario analyses to assess model uncertainty. RESULTS Over 1 year, PSV had costs of $50 951 and accrued 0.25 QALYs. Use of PAV+ mode was associated with care costs of $43 309 and 0.29 QALYs. Compared to PSV, PAV+ mode was considered likely to be cost-effective, having lower costs (-$7642) and increased QALYs (+0.04) after 1 year. In cost-effectiveness acceptability analysis, 100% of simulations would be cost-effective at a willingness-to-pay threshold of $50 000 per QALY gained. INTERPRETATION Use of PAV+ mode is expected to benefit patient care in the intensive care unit (ICU) and be a cost-effective alternative to PSV in the Canadian setting. Canadian hospital payers may therefore consider how best to optimally deliver mechanical ventilation in the ICU as they expand ICU capacity.
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Affiliation(s)
- Rhodri Saunders
- Coreva Scientific & Co (Saunders, Davis), KÖnigswinter, Germany; University of Western Ontario (Bosma); London Health Sciences Centre (Bosma), University Hospital, London, Ont
| | - Jason A Davis
- Coreva Scientific & Co (Saunders, Davis), KÖnigswinter, Germany; University of Western Ontario (Bosma); London Health Sciences Centre (Bosma), University Hospital, London, Ont
| | - Karen J Bosma
- Coreva Scientific & Co (Saunders, Davis), KÖnigswinter, Germany; University of Western Ontario (Bosma); London Health Sciences Centre (Bosma), University Hospital, London, Ont.
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57
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Gao E, Ristanoski G, Aickelin U, Berlowitz D, Howard M. Early Detection and Classification of Patient-Ventilator Asynchrony Using Machine Learning. Artif Intell Med 2022. [DOI: 10.1007/978-3-031-09342-5_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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58
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Itagaki T. Diaphragm-protective mechanical ventilation in acute respiratory failure. THE JOURNAL OF MEDICAL INVESTIGATION 2022; 69:165-172. [DOI: 10.2152/jmi.69.165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
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59
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Barati P, Ghafari S, Saghaei M. Comparative Assessment of the Effects of Two Methods of Pressure Support Adjustment on Respiratory Distress in Patients under Mechanical Ventilation Admitted to Intensive Care Units. Indian J Crit Care Med 2021; 25:1026-1030. [PMID: 34963721 PMCID: PMC8664038 DOI: 10.5005/jp-journals-10071-23960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Incorrect adjustment of the respiratory parameters of the mechanical ventilator increases respiratory distress and work of breathing (WOB) in mechanically ventilated patients. The accurate adjustment of pressure support increases thepatient's comfort and decreases respiratory distress and WOB, etc.; thus, the present study was conducted to compare the effects of two pressure support adjustment methods on respiratory distress in patients under mechanical ventilation to investigate whether the rapid shallow breathing index (RSBI)method can reduce patients’ respiratory distress more and faster than the tidal volume (VT) and respiratory rate (RR) methods. Patients and methods The study was conducted in 2020 on 56 mechanically ventilated patients with respiratory distress. The patients’ respiratory distress was first measured using RSBI and the respiratory distress observation scale (RDOS). The pressuresupport was then adjusted in the patients according to the RSBI (in the trial group, n = 33)and VT and RR (in the control group, n = 23). The patients’ respiratory distress was measured again in both groups 15 and 30 minutes after the pressure support adjustment. Results The results showed no significant differences between the two groups in the mean RSBI and RDOS before (p = 0.374, p = 0.657 respectively) and 30 (p = 0.103, p = 0.218 respectively) minutes after the adjustment of the pressure support, but these mean values differed significantly (p = 0.025 for RSBI and p = 0.044 for RDOS) between the groups 15 minutes after the adjustment. Moreover, the interaction effect of the group * time for RDOS has become significant nonlinearly (p = 0.037), but none of the interaction effects of the group * time were significant for RSBI (linear: p = 0.531; nonlinear: p = 0.272). Conclusion These two methods finally reduced the patients’ respiratory distress almost equally, but RSBI method can relieve the patients’ respiratory distress faster than the VT and RR methods. How to cite this article Barati P, Ghafari S, Saghaei M. Comparative Assessment of the Effects of Two Methods of Pressure Support Adjustment on Respiratory Distress in Patients under Mechanical Ventilation Admitted to Intensive Care Units. Indian J Crit Care Med 2021;25(9):1026–1030. Key message VT, RR, and RSBI methods finally reduced the patients’ respiratory distress almost equally, but RSBI method can relieve the patients’ respiratory distress faster than the VT and RR methods.
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Affiliation(s)
- Pooneh Barati
- Critical Care Nursing, Nursingand Midwifery Care Research Center, Faculty of Nursing and Midwifery, IsfahanUniversity of Medical Sciences, Isfahan, Iran
| | - Somayeh Ghafari
- Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mahmood Saghaei
- Department of Anesthesia, Isfahan University of Medical Sciences, Isfahan, Iran. Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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Casagrande A, Quintavalle F, Lena E, Fabris F, Lucangelo U. Pressure-flow breath representation eases asynchrony identification in mechanically ventilated patients. J Clin Monit Comput 2021; 36:1499-1508. [PMID: 34964083 PMCID: PMC8714555 DOI: 10.1007/s10877-021-00792-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 12/17/2021] [Indexed: 08/30/2023]
Abstract
Breathing asynchronies are mismatches between the requests of mechanically ventilated subjects and the support provided by mechanical ventilators. The most widespread technique in identifying these pathological conditions is the visual analysis of the intra-tracheal pressure and flow time-trends. This work considers a recently introduced pressure-flow representation technique and investigates whether it can help nurses in the early detection of anomalies that can represent asynchronies. Twenty subjects—ten Intensive Care Unit (ICU) nurses and ten persons inexperienced in medical practice—were asked to find asynchronies in 200 breaths pre-labeled by three experts. The new representation increases significantly the detection capability of the subjects—average sensitivity soared from 0.622 to 0.905—while decreasing the classification time—from 1107.0 to 567.1 s on average—at the price of a not statistically significant rise in the number of wrong identifications—specificity average descended from 0.589 to 0.52. Moreover, the differences in experience between the nurse group and the inexperienced group do not affect the sensitivity, specificity, or classification times. The pressure-flow diagram significantly increases sensitivity and decreases the response time of early asynchrony detection performed by nurses. Moreover, the data suggest that operator experience does not affect the identification results. This outcome leads us to believe that, in emergency contexts with a shortage of nurses, intensive care nurses can be supplemented, for the sole identification of possible respiratory asynchronies, by inexperienced staff.
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Affiliation(s)
- Alberto Casagrande
- Department of Mathematics and Geosciences, University of Trieste, Trieste, Italy
| | - Francesco Quintavalle
- DAI, Emergenza Urgenza ed Accettazione, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - Enrico Lena
- DAI, Emergenza Urgenza ed Accettazione, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - Francesco Fabris
- Department of Mathematics and Geosciences, University of Trieste, Trieste, Italy.
| | - Umberto Lucangelo
- DAI, Emergenza Urgenza ed Accettazione, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy.,Clinical Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
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61
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Bongiovanni F, Grieco DL, Anzellotti GM, Menga LS, Michi T, Cesarano M, Raggi V, De Bartolomeo C, Mura B, Mercurio G, D'Arrigo S, Bello G, Maviglia R, Pennisi MA, Antonelli M. Gas conditioning during helmet noninvasive ventilation: effect on comfort, gas exchange, inspiratory effort, transpulmonary pressure and patient-ventilator interaction. Ann Intensive Care 2021; 11:184. [PMID: 34952962 PMCID: PMC8708509 DOI: 10.1186/s13613-021-00972-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/12/2021] [Indexed: 01/21/2023] Open
Abstract
Background There is growing interest towards the use of helmet noninvasive ventilation (NIV) for the management of acute hypoxemic respiratory failure. Gas conditioning through heat and moisture exchangers (HME) or heated humidifiers (HHs) is needed during facemask NIV to provide a minimum level of humidity in the inspired gas (15 mg H2O/L). The optimal gas conditioning strategy during helmet NIV remains to be established. Methods Twenty patients with acute hypoxemic respiratory failure (PaO2/FiO2 < 300 mmHg) underwent consecutive 1-h periods of helmet NIV (PEEP 12 cmH2O, pressure support 12 cmH2O) with four humidification settings, applied in a random order: double-tube circuit with HHs and temperature set at 34 °C (HH34) and 37 °C (HH37); Y-piece circuit with HME; double-tube circuit with no humidification (NoH). Temperature and humidity of inhaled gas were measured through a capacitive hygrometer. Arterial blood gases, discomfort and dyspnea through visual analog scales (VAS), esophageal pressure swings (ΔPES) and simplified pressure–time product (PTPES), dynamic transpulmonary driving pressure (ΔPL) and asynchrony index were measured in each step. Results Median [IqR] absolute humidity, temperature and VAS discomfort were significantly lower during NoH vs. HME, HH34 and HH37: absolute humidity (mgH2O/L) 16 [12–19] vs. 28 [23–31] vs. 28 [24–31] vs. 33 [29–38], p < 0.001; temperature (°C) 29 [28–30] vs. 30 [29–31] vs. 31 [29–32] vs 32. [31–33], p < 0.001; VAS discomfort 4 [2–6] vs. 6 [2–7] vs. 7 [4–8] vs. 8 [4–10], p = 0.03. VAS discomfort increased with higher absolute humidity (p < 0.01) and temperature (p = 0.007). Higher VAS discomfort was associated with increased VAS dyspnea (p = 0.001). Arterial blood gases, respiratory rate, ΔPES, PTPES and ΔPL were similar in all conditions. Overall asynchrony index was similar in all steps, but autotriggering rate was lower during NoH and HME (p = 0.03). Conclusions During 1-h sessions of helmet NIV in patients with hypoxemic respiratory failure, a double-tube circuit with no humidification allowed adequate conditioning of inspired gas, optimized comfort and improved patient–ventilator interaction. Use of HHs or HME in this setting resulted in increased discomfort due to excessive heat and humidity in the interface, which was associated with more intense dyspnea. Trail Registration Registered on clinicaltrials.gov (NCT02875379) on August 23rd, 2016.
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Affiliation(s)
- Filippo Bongiovanni
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy.,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
| | - Domenico Luca Grieco
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy. .,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy.
| | - Gian Marco Anzellotti
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy.,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
| | - Luca Salvatore Menga
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy.,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
| | - Teresa Michi
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy.,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
| | - Melania Cesarano
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy.,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
| | - Valeria Raggi
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy.,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
| | - Cecilia De Bartolomeo
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy.,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
| | - Benedetta Mura
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy.,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
| | - Giovanna Mercurio
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy.,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
| | - Sonia D'Arrigo
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy.,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
| | - Giuseppe Bello
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy.,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
| | - Riccardo Maviglia
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy.,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
| | - Mariano Alberto Pennisi
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy.,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy.,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
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Muhamad Sauki NS, Damanhuri NS, Othman NA, Chiew Meng BC, Chiew YS, Mat Nor MB. Assessing the Asynchrony Event Based on the Ventilation Mode for Mechanically Ventilated Patients in ICU. Bioengineering (Basel) 2021; 8:bioengineering8120222. [PMID: 34940375 PMCID: PMC8698314 DOI: 10.3390/bioengineering8120222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/30/2021] [Accepted: 12/15/2021] [Indexed: 11/16/2022] Open
Abstract
Respiratory system modelling can assist clinicians in making clinical decisions during mechanical ventilation (MV) management in intensive care. However, there are some cases where the MV patients produce asynchronous breathing (asynchrony events) due to the spontaneous breathing (SB) effort even though they are fully sedated. Currently, most of the developed models are only suitable for fully sedated patients, which means they cannot be implemented for patients who produce asynchrony in their breathing. This leads to an incorrect measurement of the actual underlying mechanics in these patients. As a result, there is a need to develop a model that can detect asynchrony in real-time and at the bedside throughout the ventilated days. This paper demonstrates the asynchronous event detection of MV patients in the ICU of a hospital by applying a developed extended time-varying elastance model. Data from 10 mechanically ventilated respiratory failure patients admitted at the International Islamic University Malaysia (IIUM) Hospital were collected. The results showed that the model-based technique precisely detected asynchrony events (AEs) throughout the ventilation days. The patients showed an increase in AEs during the ventilation period within the same ventilation mode. SIMV mode produced much higher asynchrony compared to SPONT mode (p < 0.05). The link between AEs and the lung elastance (AUC Edrs) was also investigated. It was found that when the AEs increased, the AUC Edrs decreased and vice versa based on the results obtained in this research. The information of AEs and AUC Edrs provides the true underlying lung mechanics of the MV patients. Hence, this model-based method is capable of detecting the AEs in fully sedated MV patients and providing information that can potentially guide clinicians in selecting the optimal ventilation mode of MV, allowing for precise monitoring of respiratory mechanics in MV patients.
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Affiliation(s)
- Nur Sa’adah Muhamad Sauki
- School of Electrical Engineering, College of Engineering, Universiti Teknologi MARA, Cawangan Pulau Pinang, Permatang Pauh 13500, Malaysia; (N.S.M.S.); (N.A.O.); (B.C.C.M.)
| | - Nor Salwa Damanhuri
- School of Electrical Engineering, College of Engineering, Universiti Teknologi MARA, Cawangan Pulau Pinang, Permatang Pauh 13500, Malaysia; (N.S.M.S.); (N.A.O.); (B.C.C.M.)
- Correspondence: ; Tel.: +60-11-38715853
| | - Nor Azlan Othman
- School of Electrical Engineering, College of Engineering, Universiti Teknologi MARA, Cawangan Pulau Pinang, Permatang Pauh 13500, Malaysia; (N.S.M.S.); (N.A.O.); (B.C.C.M.)
| | - Belinda Chong Chiew Meng
- School of Electrical Engineering, College of Engineering, Universiti Teknologi MARA, Cawangan Pulau Pinang, Permatang Pauh 13500, Malaysia; (N.S.M.S.); (N.A.O.); (B.C.C.M.)
| | - Yeong Shiong Chiew
- School of Engineering, Monash University Malaysia, Bandar Sunway 47500, Malaysia;
| | - Mohd Basri Mat Nor
- Department of Anaesthesiology and Intensive Care, School of Medicine, International Islamic University of Malaysia, Kuantan 25200, Malaysia;
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Bureau C, Decavèle M, Campion S, Nierat MC, Mayaux J, Morawiec E, Raux M, Similowski T, Demoule A. Proportional assist ventilation relieves clinically significant dyspnea in critically ill ventilated patients. Ann Intensive Care 2021; 11:177. [PMID: 34919178 PMCID: PMC8683518 DOI: 10.1186/s13613-021-00958-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 11/22/2021] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Dyspnea is common and often severe symptom in mechanically ventilated patients. Proportional assist ventilation (PAV) is an assist ventilatory mode that adjusts the level of assistance to the activity of respiratory muscles. We hypothesized that PAV reduce dyspnea compared to pressure support ventilation (PSV). PATIENTS AND METHODS Mechanically ventilated patients with clinically significant dyspnea were included. Dyspnea intensity was assessed by the Dyspnea-Visual Analog Scale (D-VAS) and the Intensive Care-Respiratory Distress Observation Scale (IC-RDOS) at inclusion (PSV-Baseline), after personalization of ventilator settings in order to minimize dyspnea (PSV-Personalization), and after switch to PAV. Respiratory drive was assessed by record of electromyographic activity of inspiratory muscles, the proportion of asynchrony was analyzed. RESULTS Thirty-four patients were included (73% males, median age of 66 [57-77] years). The D-VAS score was lower with PSV-Personalization (37 mm [20‒55]) and PAV (31 mm [14‒45]) than with PSV-Baseline (62 mm [28‒76]) (p < 0.05). The IC-RDOS score was lower with PAV (4.2 [2.4‒4.7]) and PSV-Personalization (4.4 [2.4‒4.9]) than with PSV-Baseline (4.8 [4.1‒6.5]) (p < 0.05). The electromyographic activity of parasternal intercostal muscles was lower with PAV and PSV-Personalization than with PSV-Baseline. The asynchrony index was lower with PAV (0% [0‒0.55]) than with PSV-Baseline and PSV-Personalization (0.68% [0‒2.28] and 0.60% [0.31‒1.41], respectively) (p < 0.05). CONCLUSION In mechanically ventilated patients exhibiting clinically significant dyspnea with PSV, personalization of PSV settings and PAV results in not different decreased dyspnea and activity of muscles to a similar degree, even though PAV was able to reduce asynchrony more effectively.
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Affiliation(s)
- Côme Bureau
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France. .,AP-HP 6 Sorbonne Université, site Pitié-Salpêtrière, Service de Pneumologie, Médecine Intensive et Réanimation, Département R3S, Hôpital Pitié-Salpêtrière, 47-83 bld de l'hôpital, 75651, Paris cedex 13, France.
| | - Maxens Decavèle
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France.,AP-HP 6 Sorbonne Université, site Pitié-Salpêtrière, Service de Pneumologie, Médecine Intensive et Réanimation, Département R3S, Hôpital Pitié-Salpêtrière, 47-83 bld de l'hôpital, 75651, Paris cedex 13, France
| | - Sébastien Campion
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France.,AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département d'Anesthésie Réanimation, 75013, Paris, France
| | - Marie-Cécile Nierat
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France
| | - Julien Mayaux
- AP-HP 6 Sorbonne Université, site Pitié-Salpêtrière, Service de Pneumologie, Médecine Intensive et Réanimation, Département R3S, Hôpital Pitié-Salpêtrière, 47-83 bld de l'hôpital, 75651, Paris cedex 13, France
| | - Elise Morawiec
- AP-HP 6 Sorbonne Université, site Pitié-Salpêtrière, Service de Pneumologie, Médecine Intensive et Réanimation, Département R3S, Hôpital Pitié-Salpêtrière, 47-83 bld de l'hôpital, 75651, Paris cedex 13, France
| | - Mathieu Raux
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France.,AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département d'Anesthésie Réanimation, 75013, Paris, France
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France.,AP-HP 6 Sorbonne Université, site Pitié-Salpêtrière, Service de Pneumologie, Médecine Intensive et Réanimation, Département R3S, Hôpital Pitié-Salpêtrière, 47-83 bld de l'hôpital, 75651, Paris cedex 13, France
| | - Alexandre Demoule
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France.,AP-HP 6 Sorbonne Université, site Pitié-Salpêtrière, Service de Pneumologie, Médecine Intensive et Réanimation, Département R3S, Hôpital Pitié-Salpêtrière, 47-83 bld de l'hôpital, 75651, Paris cedex 13, France
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Liu L, Yu Y, Xu X, Sun Q, Qiu H, Chiumello D, Yang Y. Automatic Adjustment of the Inspiratory Trigger and Cycling-Off Criteria Improved Patient-Ventilator Asynchrony During Pressure Support Ventilation. Front Med (Lausanne) 2021; 8:752508. [PMID: 34869448 PMCID: PMC8632800 DOI: 10.3389/fmed.2021.752508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/11/2021] [Indexed: 11/28/2022] Open
Abstract
Background: Patient-ventilator asynchrony is common during pressure support ventilation (PSV) because of the constant cycling-off criteria and variation of respiratory system mechanical properties in individual patients. Automatic adjustment of inspiratory triggers and cycling-off criteria based on waveforms might be a useful tool to improve patient-ventilator asynchrony during PSV. Method: Twenty-four patients were enrolled and were ventilated using PSV with different cycling-off criteria of 10% (PS10), 30% (PS30), 50% (PS50), and automatic adjustment PSV (PSAUTO). Patient-ventilator interactions were measured. Results: The total asynchrony index (AI) and NeuroSync index were consistently lower in PSAUTO when compared with PS10, PS30, and PS50, (P < 0.05). The benefit of PSAUTO in reducing the total AI was mainly because of the reduction of the micro-AI but not the macro-AI. PSAUTO significantly improved the relative cycling-off error when compared with prefixed controlled PSV (P < 0.05). PSAUTO significantly reduced the trigger error and inspiratory effort for the trigger when compared with a prefixed trigger. However, total inspiratory effort, breathing patterns, and respiratory drive were not different among modes. Conclusions: When compared with fixed cycling-off criteria, an automatic adjustment system improved patient-ventilator asynchrony without changes in breathing patterns during PSV. The automatic adjustment system could be a useful tool to titrate more personalized mechanical ventilation.
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Affiliation(s)
- Ling Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yue Yu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Xiaoting Xu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Qin Sun
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Davide Chiumello
- SC Anesthesia and Resuscitation, San Paolo Hospital-University Campus, ASST Santi Paolo e Carlo, Milan, Italy.,Department of Health Sciences, University of Milan, Milan, Italy.,Coordinated Research Center of Respiratory Insufficiency, University of Milan, Milan, Italy
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
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Abstract
OBJECTIVES To explore the level and time course of patient-ventilator asynchrony in mechanically ventilated children and the effects on duration of mechanical ventilation, PICU stay, and Comfort Behavior Score as indicator for patient comfort. DESIGN Secondary analysis of physiology data from mechanically ventilated children. SETTING Mixed medical-surgical tertiary PICU in a university hospital. PATIENTS Mechanically ventilated children 0-18 years old were eligible for inclusion. Excluded were patients who were unable to initiate and maintain spontaneous breathing from any cause. MEASUREMENTS AND MAIN RESULTS Twenty-nine patients were studied with a total duration of 109 days. Twenty-two study days (20%) were excluded because patients were on neuromuscular blockade or high-frequency oscillatory ventilation, yielding 87 days (80%) for analysis. Patient-ventilator asynchrony was detected through analysis of daily recorded ventilator airway pressure, flow, and volume versus time scalars. Approximately one of every three breaths was asynchronous. The percentage of asynchronous breaths significantly increased over time, with the highest prevalence on the day of extubation. There was no correlation with the Comfort Behavior score. The percentage of asynchronous breaths during the first 24 hours was inversely correlated with the duration of mechanical ventilation. Patients with severe patient-ventilator asynchrony (asynchrony index > 10% or > 75th percentile of the calculated asynchrony index) did not have a prolonged duration of ventilation. CONCLUSIONS The level of patient-ventilator asynchrony increased over time was not related to patient discomfort and inversely related to the duration of mechanical ventilation.
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Jhou HJ, Chen PH, Ou-Yang LJ, Lin C, Tang SE, Lee CH. Methods of Weaning From Mechanical Ventilation in Adult: A Network Meta-Analysis. Front Med (Lausanne) 2021; 8:752984. [PMID: 34671629 PMCID: PMC8521009 DOI: 10.3389/fmed.2021.752984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 09/13/2021] [Indexed: 12/16/2022] Open
Abstract
Background/Objective: The aim of study is to assess the efficacy of each ventilator weaning method for ventilated patients in intensive care units (ICUs). Methods: A systematic search was conducted using PubMed, Embase, and China National Knowledge Infrastructure to identify randomized control studies on ventilated patients regarding extubation associated outcomes (weaning success or failure, proportion requiring re-intubation, or mortality) from inception until April 01, 2020. Commonly used ventilation modes involved pressure support ventilation, synchronized intermittent mandatory ventilation, automatic tube compensation, continuous positive airway pressure, adaptive support ventilation, neurally adjusted ventilatory assist, proportional assisted ventilation, and SmartCare. Pooled estimates regarding extubation associated outcomes were calculated using network meta-analysis. Results: Thirty-nine randomized controlled trials including 5,953 patients met inclusion criteria. SmartCare and proportional assist ventilation were found to be effective methods in increasing weaning success (odds ratio, 2.72, 95% confidence interval (CI), 1.33–5.58, P-score: 0.84; odds ratio, 2.56, 95% CI, 1.60–4.11, P-score: 0.83; respectively). Besides, proportional assist ventilation had superior in reducing proportion requiring re-intubation rate (odds ratio, 0.48, 95% CI, 0.25–0.92, P-score: 0.89) and mortality (odds ratio, 0.48, 95% CI, 0.26–0.92, P-score: 0.91) than others. Conclusion: In general consideration, our study provided evidence that weaning with proportional assist ventilation has a high probability of being the most effective ventilation mode for patients with mechanical ventilation regarding a higher rate of weaning success, a lower proportion requiring reintubation, and a lower mortality rate than other ventilation modes.
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Affiliation(s)
- Hong-Jie Jhou
- Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan.,School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Po-Huang Chen
- Department of General Medicine, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan.,Department of Internal Medicine, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan
| | - Liang-Jun Ou-Yang
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chin Lin
- School of Public Health, National Defense Medical Center, Taipei, Taiwan.,Department of Research and Development, National Defense Medical Center, Taipei, Taiwan
| | - Shih-En Tang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan.,National Defense Medical Center, Graduate Institute of Aerospace and Undersea Medicine, Taipei, Taiwan
| | - Cho-Hao Lee
- Division of Hematology and Oncology Medicine, Department of Internal Medicine, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan
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Haudebourg AF, Maraffi T, Tuffet S, Perier F, de Prost N, Razazi K, Mekontso Dessap A, Carteaux G. Refractory ineffective triggering during pressure support ventilation: effect of proportional assist ventilation with load-adjustable gain factors. Ann Intensive Care 2021; 11:147. [PMID: 34669080 PMCID: PMC8527439 DOI: 10.1186/s13613-021-00935-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 10/07/2021] [Indexed: 12/21/2022] Open
Abstract
Background Ineffective triggering is frequent during pressure support ventilation (PSV) and may persist despite ventilator adjustment, leading to refractory asynchrony. We aimed to assess the effect of proportional assist ventilation with load-adjustable gain factors (PAV+) on the occurrence of refractory ineffective triggering. Design Observational assessment followed by prospective cross-over physiological study. Setting Academic medical ICU. Patients Ineffective triggering was detected during PSV by a twice-daily inspection of the ventilator’s screen. The impact of pressure support level (PSL) adjustments on the occurrence of asynchrony was recorded. Patients experiencing refractory ineffective triggering, defined as persisting asynchrony at the lowest tolerated PSL, were included in the physiological study. Interventions Physiological study: Flow, airway, and esophageal pressures were continuously recorded during 10 min under PSV with the lowest tolerated PSL, and then under PAV+ with the gain adjusted to target a muscle pressure between 5 and 10 cmH2O. Measurements Primary endpoint was the comparison of asynchrony index between PSV and PAV+ after PSL and gain adjustments. Results Among 36 patients identified having ineffective triggering under PSV, 21 (58%) exhibited refractory ineffective triggering. The lowest tolerated PSL was higher in patients with refractory asynchrony as compared to patients with non-refractory ineffective triggering. Twelve out of the 21 patients with refractory ineffective triggering were included in the physiological study. The median lowest tolerated PSL was 17 cmH2O [12–18] with a PEEP of 7 cmH2O [5–8] and FiO2 of 40% [39–42]. The median gain during PAV+ was 73% [65–80]. The asynchrony index was significantly lower during PAV+ than PSV (2.7% [1.0–5.4] vs. 22.7% [10.3–40.1], p < 0.001) and consistently decreased in every patient with PAV+. Esophageal pressure–time product (PTPes) did not significantly differ between the two modes (107 cmH2O/s/min [79–131] under PSV vs. 149 cmH2O/s/min [129–170] under PAV+, p = 0.092), but the proportion of PTPes lost in ineffective triggering was significantly lower with PAV+ (2 cmH2O/s/min [1–6] vs. 8 cmH2O/s/min [3–30], p = 0.012). Conclusions Among patients with ineffective triggering under PSV, PSL adjustment failed to eliminate asynchrony in 58% of them (21 of 36 patients). In these patients with refractory ineffective triggering, switching from PSV to PAV+ significantly reduced or even suppressed the incidence of asynchrony. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00935-0.
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Affiliation(s)
- Anne-Fleur Haudebourg
- Service de Médecine Intensive Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France. .,Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France.
| | - Tommaso Maraffi
- Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France.,Service de Réanimation et Surveillance Continue Adulte, Centre hospitalier intercommunal de Créteil, 94000, Créteil, France
| | - Samuel Tuffet
- Service de Médecine Intensive Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France.,Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France.,Institut Mondor de Recherche Biomédicale INSERM 955, Créteil, France
| | - François Perier
- Service de Médecine Intensive Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France.,Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France
| | - Nicolas de Prost
- Service de Médecine Intensive Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France.,Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France
| | - Keyvan Razazi
- Service de Médecine Intensive Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France.,Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France
| | - Armand Mekontso Dessap
- Service de Médecine Intensive Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France.,Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France
| | - Guillaume Carteaux
- Service de Médecine Intensive Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France.,Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France.,Institut Mondor de Recherche Biomédicale INSERM 955, Créteil, France
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Accuracy of Algorithms and Visual Inspection for Detection of Trigger Asynchrony in Critical Patients : A Systematic Review. Crit Care Res Pract 2021; 2021:6942497. [PMID: 34621546 PMCID: PMC8492248 DOI: 10.1155/2021/6942497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 09/04/2021] [Indexed: 11/29/2022] Open
Abstract
Objective This study aimed to summarize the accuracy of the different methods for detecting trigger asynchrony at the bedside in mechanically ventilated patients. Method A systematic review was conducted from 1990 to 2020 in PubMed, Lilacs, Scopus, and ScienceDirect databases. The reference list of the identified studies, reviews, and meta-analyses was also manually searched for relevant studies. The reference standards were esophageal pressure catheter and/or electrical activity of the diaphragm. Studies were assessed following the QUADAS-2 recommendations, while the review was prepared according to the PRISMA criteria. Results One thousand one hundred and eleven studies were selected, and four were eligible for analysis. Esophageal pressure was the predominant reference standard, while visual inspection and algorithms/software comprised index tests. The trigger asynchrony, ineffective expiratory effort, double triggering, and reverse triggering were analyzed. Sensitivity and specificity ranged from 65.2% to 99% and 80% to 100%, respectively. Positive predictive values reached 80.3 to 100%, while the negative predictive values reached 92 to 100%. Accuracy could not be calculated for most studies. Conclusion Algorithms/software validated directly or indirectly using reference standards present high sensitivity and specificity, with a diagnostic power similar to visual inspection of experts.
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69
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Benítez Lozano J, de la Fuente Martos C, Serrano Simón J. Doble trigger y ¿falso? reverse trigger. Med Intensiva 2021. [DOI: 10.1016/j.medin.2019.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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70
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Harris J, Tibby SM, Endacott R, Latour JM. Neurally Adjusted Ventilator Assist in Infants With Acute Respiratory Failure: A Literature Scoping Review. Pediatr Crit Care Med 2021; 22:915-924. [PMID: 33852545 DOI: 10.1097/pcc.0000000000002727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To map the evidence for neurally adjusted ventilatory assist strategies, outcome measures, and sedation practices in infants less than 12 months with acute respiratory failure using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidance. DATA SOURCES CINAHL, MEDLINE, COCHRANE, JBI, EMBASE, PsycINFO, Google scholar, BNI, AMED. Trial registers included the following: ClinicalTrials.gov, European Union clinical trials register, International Standardized Randomized Controlled Trial Number register. Also included were Ethos, Grey literature, Google, dissertation abstracts, EMBASE conference proceedings. STUDY SELECTION Abstracts were screened followed by review of full text. Articles incorporating a heterogeneous population of both infants and older children were assessed, and where possible, data for infants were extracted. Fifteen articles were included. Ten articles were primary research: randomized controlled trial (n = 3), cohort studies (n = 4), retrospective data analysis (n = 2), case series (n = 1). Other articles are expert opinion (n = 2), neurally adjusted ventilatory assist updates (n = 1), and a literature review (n = 2). Three studies included exclusively infants. We also included 12 studies reporting jointly on infants and children. DATA EXTRACTION A standardized data extraction tool was used. DATA SYNTHESIS Key findings were that evidence related to neurally adjusted ventilatory assist ventilation strategies in infants and related to specific primary conditions is limited. The setting of neurally adjusted ventilatory assist level is not consistent, and how to optimize this mode of ventilation was not documented. Outcome measures varied considerably, most studies focused on improvements in respiratory and physiological variables. Sedation use is variable with regard to medication type and dose. There is an indication that less sedation is required in patients receiving neurally adjusted ventilatory assist, but no conclusive evidence to support this. CONCLUSIONS This review highlights a lack of standardized strategies for neurally adjusted ventilatory assist ventilation and sedation practices among infants with acute respiratory failure. Studies were limited by small sample sizes and a lack of focus on specific patient groups. Robust studies are needed to provide evidence-based clinical recommendations for the use of neurally adjusted ventilatory assist in infants with acute respiratory failure.
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Affiliation(s)
- Julia Harris
- Department of Advanced and Integrated Practice, London South Bank University, London, United Kingdom
- Department of Children's Nursing, School of Nursing and Midwifery, Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth, Plymouth, United Kingdom
| | - Shane M Tibby
- Pediatric Intensive Care, Evelina London Children's Hospital, London, United Kingdom
| | - Ruth Endacott
- Department of Children's Nursing, School of Nursing and Midwifery, Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth, Plymouth, United Kingdom
- School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston, VIC, Australia
| | - Jos M Latour
- Department of Children's Nursing, School of Nursing and Midwifery, Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth, Plymouth, United Kingdom
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De Oliveira B, Aljaberi N, Taha A, Abduljawad B, Hamed F, Rahman N, Mallat J. Patient-Ventilator Dyssynchrony in Critically Ill Patients. J Clin Med 2021; 10:jcm10194550. [PMID: 34640566 PMCID: PMC8509510 DOI: 10.3390/jcm10194550] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/20/2021] [Accepted: 09/27/2021] [Indexed: 11/16/2022] Open
Abstract
Patient–ventilator dyssynchrony is a mismatch between the patient’s respiratory efforts and mechanical ventilator delivery. Dyssynchrony can occur at any phase throughout the respiratory cycle. There are different types of dyssynchrony with different mechanisms and different potential management: trigger dyssynchrony (ineffective efforts, autotriggering, and double triggering); flow dyssynchrony, which happens during the inspiratory phase; and cycling dyssynchrony (premature cycling and delayed cycling). Dyssynchrony has been associated with patient outcomes. Thus, it is important to recognize and address these dyssynchronies at the bedside. Patient–ventilator dyssynchrony can be detected by carefully scrutinizing the airway pressure–time and flow–time waveforms displayed on the ventilator screens along with assessing the patient’s comfort. Clinicians need to know how to depict these dyssynchronies at the bedside. This review aims to define the different types of dyssynchrony and then discuss the evidence for their relationship with patient outcomes and address their potential management.
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Affiliation(s)
- Bruno De Oliveira
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi P.O. Box 112412, United Arab Emirates; (B.D.O.); (N.A.); (A.T.); (B.A.); (F.H.); (N.R.)
| | - Nahla Aljaberi
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi P.O. Box 112412, United Arab Emirates; (B.D.O.); (N.A.); (A.T.); (B.A.); (F.H.); (N.R.)
| | - Ahmed Taha
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi P.O. Box 112412, United Arab Emirates; (B.D.O.); (N.A.); (A.T.); (B.A.); (F.H.); (N.R.)
| | - Baraa Abduljawad
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi P.O. Box 112412, United Arab Emirates; (B.D.O.); (N.A.); (A.T.); (B.A.); (F.H.); (N.R.)
| | - Fadi Hamed
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi P.O. Box 112412, United Arab Emirates; (B.D.O.); (N.A.); (A.T.); (B.A.); (F.H.); (N.R.)
| | - Nadeem Rahman
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi P.O. Box 112412, United Arab Emirates; (B.D.O.); (N.A.); (A.T.); (B.A.); (F.H.); (N.R.)
| | - Jihad Mallat
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi P.O. Box 112412, United Arab Emirates; (B.D.O.); (N.A.); (A.T.); (B.A.); (F.H.); (N.R.)
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH 44195, USA
- Faculty of Medicine, Normandy University, UNICAEN, ED 497, 1400 Caen, France
- Department of Anesthesiology and Critical Care Medicine, Centre Hospitalier de Lens, 62300 Lens, France
- Correspondence:
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Thompson AF, Moraes L, Rocha NN, Fernandes MVS, Antunes MA, Abreu SC, Santos CL, Capelozzi VL, Samary CS, de Abreu MG, Saddy F, Pelosi P, Silva PL, Rocco PRM. Impact of different frequencies of controlled breath and pressure-support levels during biphasic positive airway pressure ventilation on the lung and diaphragm in experimental mild acute respiratory distress syndrome. PLoS One 2021; 16:e0256021. [PMID: 34415935 PMCID: PMC8378704 DOI: 10.1371/journal.pone.0256021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 07/28/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND We hypothesized that a decrease in frequency of controlled breaths during biphasic positive airway pressure (BIVENT), associated with an increase in spontaneous breaths, whether pressure support (PSV)-assisted or not, would mitigate lung and diaphragm damage in mild experimental acute respiratory distress syndrome (ARDS). MATERIALS AND METHODS Wistar rats received Escherichia coli lipopolysaccharide intratracheally. After 24 hours, animals were randomly assigned to: 1) BIVENT-100+PSV0%: airway pressure (Phigh) adjusted to VT = 6 mL/kg and frequency of controlled breaths (f) = 100 bpm; 2) BIVENT-50+PSV0%: Phigh adjusted to VT = 6 mL/kg and f = 50 bpm; 3) BIVENT-50+PSV50% (PSV set to half the Phigh reference value, i.e., PSV50%); or 4) BIVENT-50+PSV100% (PSV equal to Phigh reference value, i.e., PSV100%). Positive end-expiratory pressure (Plow) was equal to 5 cmH2O. Nonventilated animals were used for lung and diaphragm histology and molecular biology analysis. RESULTS BIVENT-50+PSV0%, compared to BIVENT-100+PSV0%, reduced the diffuse alveolar damage (DAD) score, the expression of amphiregulin (marker of alveolar stretch) and muscle atrophy F-box (marker of diaphragm atrophy). In BIVENT-50 groups, the increase in PSV (BIVENT-50+PSV50% versus BIVENT-50+PSV100%) yielded better lung mechanics and less alveolar collapse, interstitial edema, cumulative DAD score, as well as gene expressions associated with lung inflammation, epithelial and endothelial cell damage in lung tissue, and muscle ring finger protein 1 (marker of muscle proteolysis) in diaphragm. Transpulmonary peak pressure (Ppeak,L) and pressure-time product per minute (PTPmin) at Phigh were associated with lung damage, while increased spontaneous breathing at Plow did not promote lung injury. CONCLUSION In the ARDS model used herein, during BIVENT, the level of PSV and the phase of the respiratory cycle in which the inspiratory effort occurs affected lung and diaphragm damage. Partitioning of inspiratory effort and transpulmonary pressure in spontaneous breaths at Plow and Phigh is required to minimize VILI.
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Affiliation(s)
- Alessandra F. Thompson
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
- Copa D’Or Hospital, Rio de Janeiro, Brazil
| | - Lillian Moraes
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Nazareth N. Rocha
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
- Department of Physiology and Pharmacology, Biomedical Institute, Fluminense Federal University, Niterói, Brazil
| | - Marcos V. S. Fernandes
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Mariana A. Antunes
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Soraia C. Abreu
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Cintia L. Santos
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Vera L. Capelozzi
- Department of Pathology, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Cynthia S. Samary
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
- Department of Physical Therapy, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Marcelo G. de Abreu
- Department of Anesthesiology and Intensive Care Therapy, Pulmonary Engineering Group, University Hospital Dresden, Technische Universität Dresden, Dresden, Germany
- Outcomes Research Consortium, Cleveland, OH, United States of America
| | - Felipe Saddy
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
- Copa D’Or Hospital, Rio de Janeiro, Brazil
- Pró-Cardíaco Hospital, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Pedro L. Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Patricia R. M. Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
- * E-mail:
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Frequency and Risk Factors for Reverse Triggering in Pediatric Acute Respiratory Distress Syndrome during Synchronized Intermittent Mandatory Ventilation. Ann Am Thorac Soc 2021; 18:820-829. [PMID: 33326335 DOI: 10.1513/annalsats.202008-1072oc] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: Reverse triggering (RT) occurs when respiratory effort begins after a mandatory breath is initiated by the ventilator. RT may exacerbate ventilator-induced lung injury and lead to breath stacking.Objectives: We sought to describe the frequency and risk factors for RT among patients with acute respiratory distress syndrome (ARDS) and identify risk factors for breath stacking.Methods: We performed a secondary analysis of physiologic data from children on synchronized intermittent mandatory pressure-controlled ventilation enrolled in a single-center randomized controlled trial for ARDS. When children had a spontaneous effort on esophageal manometry, waveforms were recorded and independently analyzed by two investigators to identify RT.Results: We included 81,990 breaths from 100 patient-days and 36 patients. Overall, 2.46% of breaths were RTs, occurring in 15/36 patients (41.6%). A higher tidal volume and a minimal difference between neural respiratory rate and set ventilator rate were independently associated with RT (P = 0.001) in multivariable modeling. Breath stacking occurred in 534 (26.5%) of 2,017 RT breaths and in 14 (93.3%) of 15 patients with RT. In multivariable modeling, breath stacking was more likely to occur when total airway Δpressure (peak inspiratory pressure - positive end-expiratory pressure [PEEP]) at the time patient effort began, peak inspiratory pressure, PEEP, and Δpressure were lower and when patient effort started well after the ventilator-initiated breath (higher phase angle) (all P < 0.05). Together, these parameters were highly predictive of breath stacking (area under the curve, 0.979).Conclusions: Patients with higher tidal volume who have a set ventilator rate close to their spontaneous respiratory rate are more likely to have RT, which results in breath stacking >25% of the time.Clinical trial registered with ClinicalTrials.gov (NCT03266016).
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Arellano-Pérez Ó, Castillo Merino F, Torres-Tejeiro R, Ugarte Ubiergo S. An assessment of esophageal balloon use for the titration of airway pressure release ventilation and controlled mechanical ventilation in a patient with extrapulmonary acute respiratory distress syndrome: a case report. J Med Case Rep 2021; 15:435. [PMID: 34399842 PMCID: PMC8367393 DOI: 10.1186/s13256-021-02984-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 06/25/2021] [Indexed: 11/10/2022] Open
Abstract
Background Esophageal pressure measurement is a minimally invasive monitoring process that assesses respiratory mechanics in patients with acute respiratory distress syndrome. Airway pressure release ventilation is a relatively new positive pressure ventilation modality, characterized by a series of advantages in patients with acute respiratory distress syndrome. Case presentation We report a case of a 55-year-old chilean female, with preexisting hypertension and recurrent renal colic who entered the cardiosurgical intensive care unit with signs and symptoms of urinary sepsis secondary to a right-sided obstructive urolithiasis. At the time of admission, the patient showed signs of urinary sepsis, a poor overall condition, hemodynamic instability, tachycardia, hypotension, and needed vasoactive drugs. Initially the patient was treated with volume control ventilation. Then, ventilation was with conventional ventilation parameters described by the Acute Respiratory Distress Syndrome Network. However, hemodynamic complications led to reduced airway pressure. Later she presented intraabdominal hypertension that compromised the oxygen supply and her ventilation management. Considering these records, an esophageal manometry was used to measure distending lung pressure, that is, transpulmonary pressure, to protect lungs. Initial use of the esophageal balloon was in a volume-controlled modality (deep sedation), which allowed the medical team to perform inspiratory and expiratory pause maneuvers to monitor transpulmonary plateau pressure as a substitute for pulmonary distension and expiratory pause and determine transpulmonary positive end-expiratory pressure. On the third day of mechanical respiration, the modality was switched to airway pressure release ventilation. The use of airway pressure release ventilation was associated with reduced hemodynamic complications and kept transpulmonary pressure between 0 and 20 cmH2O despite a sustained high positive end-expiratory pressure of 20 cmH2O. Conclusion The application of this technique is shown in airway pressure release ventilation with spontaneous ventilation, which is then compared with a controlled modality that requires a lesser number of sedative doses and vasoactive drugs, without altering the criteria for lung protection as guided by esophageal manometry.
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Affiliation(s)
- Óscar Arellano-Pérez
- Adult Patients Critical Center, INDISA Clinic, Santiago, Chile. .,School of Physical Therapy, Faculty of Health, Bernardo O'Higgins University, Santiago, Chile.
| | - Felipe Castillo Merino
- Adult Patients Critical Center, INDISA Clinic, Santiago, Chile.,School of Physical Therapy, Faculty of Rehabilitation Sciences, Andrés Bello University, Santiago, Chile
| | - Roberto Torres-Tejeiro
- Adult Patients Critical Center, INDISA Clinic, Santiago, Chile.,School of Physical Therapy, Faculty of Rehabilitation Sciences, Andrés Bello University, Santiago, Chile
| | - Sebastián Ugarte Ubiergo
- Adult Patients Critical Center, INDISA Clinic, Santiago, Chile.,Faculty of Medicine, Andrés Bello University, Santiago, Chile.,Latin American Critical Care Trial Investigative Network (LACCTIN), Santiago, Chile
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Kyo M, Shimatani T, Hosokawa K, Taito S, Kataoka Y, Ohshimo S, Shime N. Patient-ventilator asynchrony, impact on clinical outcomes and effectiveness of interventions: a systematic review and meta-analysis. J Intensive Care 2021; 9:50. [PMID: 34399855 PMCID: PMC8365272 DOI: 10.1186/s40560-021-00565-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/03/2021] [Indexed: 12/16/2022] Open
Abstract
Background Patient–ventilator asynchrony (PVA) is a common problem in patients undergoing invasive mechanical ventilation (MV) in the intensive care unit (ICU), and may accelerate lung injury and diaphragm mis-contraction. The impact of PVA on clinical outcomes has not been systematically evaluated. Effective interventions (except for closed-loop ventilation) for reducing PVA are not well established. Methods We performed a systematic review and meta-analysis to investigate the impact of PVA on clinical outcomes in patients undergoing MV (Part A) and the effectiveness of interventions for patients undergoing MV except for closed-loop ventilation (Part B). We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, ClinicalTrials.gov, and WHO-ICTRP until August 2020. In Part A, we defined asynchrony index (AI) ≥ 10 or ineffective triggering index (ITI) ≥ 10 as high PVA. We compared patients having high PVA with those having low PVA. Results Eight studies in Part A and eight trials in Part B fulfilled the eligibility criteria. In Part A, five studies were related to the AI and three studies were related to the ITI. High PVA may be associated with longer duration of mechanical ventilation (mean difference, 5.16 days; 95% confidence interval [CI], 2.38 to 7.94; n = 8; certainty of evidence [CoE], low), higher ICU mortality (odds ratio [OR], 2.73; 95% CI 1.76 to 4.24; n = 6; CoE, low), and higher hospital mortality (OR, 1.94; 95% CI 1.14 to 3.30; n = 5; CoE, low). In Part B, interventions involving MV mode, tidal volume, and pressure-support level were associated with reduced PVA. Sedation protocol, sedation depth, and sedation with dexmedetomidine rather than propofol were also associated with reduced PVA. Conclusions PVA may be associated with longer MV duration, higher ICU mortality, and higher hospital mortality. Physicians may consider monitoring PVA and adjusting ventilator settings and sedatives to reduce PVA. Further studies with adjustment for confounding factors are warranted to determine the impact of PVA on clinical outcomes. Trial registration protocols.io (URL: https://www.protocols.io/view/the-impact-of-patient-ventilator-asynchrony-in-adu-bsqtndwn, 08/27/2020). Supplementary Information The online version contains supplementary material available at 10.1186/s40560-021-00565-5.
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Affiliation(s)
- Michihito Kyo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi 1-2-3, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Tatsutoshi Shimatani
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi 1-2-3, Minami-ku, Hiroshima, 734-8551, Japan
| | - Koji Hosokawa
- Department of Anesthesiology and Reanimatology, Faculty of Medicine Sciences, University of Fukui, 23-3 Eiheijicho, Yoshidagun, Fukui, 910-1193, Japan
| | - Shunsuke Taito
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, Kasumi 1-2-3, Minami-ku, Hiroshima, 734-8551, Japan.,Systematic Review Workshop Peer Support Group (SRWS-PSG), Osaka, Japan
| | - Yuki Kataoka
- Department of Internal Medicine, Kyoto Min-Iren Asukai Hospital, Tanaka Asukai-cho 89, Sakyo-ku, Kyoto, 606-8226, Japan.,Systematic Review Workshop Peer Support Group (SRWS-PSG), Osaka, Japan.,Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan.,Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi 1-2-3, Minami-ku, Hiroshima, 734-8551, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi 1-2-3, Minami-ku, Hiroshima, 734-8551, Japan
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Raschke RA, Stoffer B, Assar S, Fountain S, Olsen K, Heise CW, Gallo T, Padilla-Jones A, Gerkin R, Parthasarathy S, Curry SC. The relationship of tidal volume and driving pressure with mortality in hypoxic patients receiving mechanical ventilation. PLoS One 2021; 16:e0255812. [PMID: 34370773 PMCID: PMC8351937 DOI: 10.1371/journal.pone.0255812] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 07/23/2021] [Indexed: 12/04/2022] Open
Abstract
PURPOSE To determine whether tidal volume/predicted body weight (TV/PBW) or driving pressure (DP) are associated with mortality in a heterogeneous population of hypoxic mechanically ventilated patients. METHODS A retrospective cohort study involving 18 intensive care units included consecutive patients ≥18 years old, receiving mechanical ventilation for ≥3 days, with a PaO2/FiO2 ratio ≤300 mmHg, whether or not they met full criteria for ARDS. The main outcome was hospital mortality. Multiple logistic regression (MLR) incorporated TV/PBW, DP, and potential confounders including age, APACHE IVa® predicted hospital mortality, respiratory system compliance (CRS), and PaO2/FiO2. Predetermined strata of TV/PBW were compared using MLR. RESULTS Our cohort comprised 5,167 patients with mean age 61.9 years, APACHE IVa® score 79.3, PaO2/FiO2 166 mmHg and CRS 40.5 ml/cm H2O. Regression analysis revealed that patients receiving DP one standard deviation above the mean or higher (≥19 cmH20) had an adjusted odds ratio for mortality (ORmort) = 1.10 (95% CI: 1.06-1.13, p = 0.009). Regression analysis showed a U-shaped relationship between strata of TV/PBW and adjusted mortality. Using TV/PBW 4-6 ml/kg as the referent group, patients receiving >10 ml/kg had similar adjusted ORmort, but those receiving 6-7, 7-8 and 8-10 ml/kg had lower adjusted ORmort (95%CI) of 0.81 (0.65-1.00), 0.78 (0.63-0.97) and 0.80 0.67-1.01) respectively. The adjusted ORmort in patients receiving 4-6 ml/kg was 1.26 (95%CI: 1.04-1.52) compared to patients receiving 6-10 ml/kg. CONCLUSIONS Driving pressures ≥19 cmH2O were associated with increased adjusted mortality. TV/PBW 4-6ml/kg were used in less than 15% of patients and associated with increased adjusted mortality compared to TV/PBW 6-10 ml/kg used in 82% of patients. Prospective clinical trials are needed to prove whether limiting DP or the use of TV/PBW 6-10 ml/kg versus 4-6 ml/kg benefits mortality.
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Affiliation(s)
- Robert A. Raschke
- The Division of Clinical Data Analytics and Decision Support, Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States of America
| | - Brenda Stoffer
- Information Technology, Banner Health, Phoenix, AZ, United States of America
| | - Seth Assar
- Pulmonary Critical Care Medicine Fellowship, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States of America
| | - Stephanie Fountain
- Pulmonary Critical Care Medicine Fellowship, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States of America
| | - Kurt Olsen
- Pulmonary Critical Care Medicine Fellowship, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States of America
| | - C. William Heise
- The Division of Clinical Data Analytics and Decision Support, Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States of America
| | - Tyler Gallo
- The Division of Clinical Data Analytics and Decision Support, Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States of America
| | - Angela Padilla-Jones
- The Division of Clinical Data Analytics and Decision Support, Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States of America
- Department of Medical Toxicology, Banner—University Medical Center Phoenix, Phoenix, AZ, United States of America
| | - Richard Gerkin
- The Division of Clinical Data Analytics and Decision Support, Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States of America
- Department of Medicine, Banner—University Medical Center—Phoenix, Phoenix, AZ, United States of America
| | - Sairam Parthasarathy
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine University of Arizona College of Medicine, Tucson, AZ, United States of America
| | - Steven C. Curry
- The Division of Clinical Data Analytics and Decision Support, Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States of America
- Department of Medical Toxicology, Banner—University Medical Center Phoenix, Phoenix, AZ, United States of America
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McKinney RL, Keszler M, Truog WE, Norberg M, Sindelar R, Wallström L, Schulman B, Gien J, Abman SH. Multicenter Experience with Neurally Adjusted Ventilatory Assist in Infants with Severe Bronchopulmonary Dysplasia. Am J Perinatol 2021; 38:e162-e166. [PMID: 32208500 DOI: 10.1055/s-0040-1708559] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The aim of this study is to determine patterns of neurally adjusted ventilatory assist (NAVA) use in ventilator-dependent preterm infants with evolving or established severe bronchopulmonary dysplasia (sBPD) among centers of the BPD Collaborative, including indications for its initiation, discontinuation, and outcomes. STUDY DESIGN Retrospective review of infants with developing or established sBPD who were placed on NAVA after ≥4 weeks of mechanical ventilation and were ≥ 30 weeks of postmenstrual age (PMA). RESULTS Among the 13 sites of the BPD collaborative, only four centers (31%) used NAVA in the management of infants with evolving or established BPD. A total of 112 patients met inclusion criteria from these four centers. PMA, weight at the start of NAVA and median number of days on NAVA, were different among the four centers. The impact of NAVA therapy was assessed as being successful in 67% of infants, as defined by the ability to achieve respiratory stability at a lower level of ventilator support, including extubation to noninvasive positive pressure ventilation or support with a home ventilator. In total 87% (range: 78-100%) of patients survived until discharge. CONCLUSION We conclude that NAVA can be used safely and effectively in selective infants with sBPD. Indications and current strategies for the application of NAVA in infants with evolving or established BPD, however, are highly variable between centers. Although this pilot study suggests that NAVA may be successfully used for the management of infants with BPD, sufficient experience and well-designed clinical studies are needed to establish standards of care for defining the role of NAVA in the care of infants with sBPD.
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Affiliation(s)
- Robin L McKinney
- Department of Pediatric Critical Care Medicine, Alpert Medical School of Brown University, Hasbro Children's Hospital, Providence, Rhode Island
| | - Martin Keszler
- Department of Pediatrics, Alpert Medical School of Brown University, Women and Infants Hospital, Providence, Rhode Island
| | - William E Truog
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Michael Norberg
- Department of Neonatology, Children's Mercy Hospital, Kansas City, Missouri
| | - Richard Sindelar
- Division of Neonatology, Department of Women's and Children's Health Uppsala University Children's Hospital, Uppsala, Sweden
| | - Linda Wallström
- Division of Neonatology, Department of Women's and Children's Health Uppsala University Children's Hospital, Uppsala, Sweden
| | - Bruce Schulman
- Department of Neonatology, Joe DiMaggio Children's Hospital, Hollywood, Florida
| | - Jason Gien
- Department of Pediatrics, University of Colorado Anschutz Medical Center and Children's Hospital Colorado, Aurora, Colorado
| | - Steven H Abman
- Department of Pediatrics, University of Colorado Anschutz Medical Center and Children's Hospital Colorado, Aurora, Colorado
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Neurally-Adjusted Ventilatory Assist (NAVA) versus Pneumatically Synchronized Ventilation Modes in Children Admitted to PICU. J Clin Med 2021; 10:jcm10153393. [PMID: 34362173 PMCID: PMC8347771 DOI: 10.3390/jcm10153393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/27/2021] [Accepted: 07/29/2021] [Indexed: 12/02/2022] Open
Abstract
Traditionally, invasively ventilated children in the paediatric intensive care unit (PICU) are weaned using pneumatically-triggered ventilation modes with a fixed level of assist. The best weaning mode is currently not known. Neurally adjusted ventilatory assist (NAVA), a newer weaning mode, uses the electrical activity of the diaphragm (Edi) to synchronise ventilator support proportionally to the patient’s respiratory drive. We aimed to perform a systematic literature review to assess the effect of NAVA on clinical outcomes in invasively ventilated children with non-neonatal lung disease. Three studies (n = 285) were included for analysis. One randomised controlled trial (RCT) of all comers showed a significant reduction in PICU length of stay and sedative use. A cohort study of acute respiratory distress syndrome (ARDS) patients (n = 30) showed a significantly shorter duration of ventilation and improved sedation with the use of NAVA. A cohort study of children recovering from cardiac surgery (n = 75) showed significantly higher extubation success, shorter duration of ventilation and PICU length of stay, and a reduction in sedative use. Our systematic review presents weak evidence that NAVA may shorten the duration of ventilation and PICU length of stay, and reduce the requirement of sedatives. However, further RCTs are required to more fully assess the effect of NAVA on clinical outcomes and treatment costs in ventilated children.
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79
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Benítez Lozano JA, de la Fuente Martos C, Serrano Simón JM. Double trigger and Pseudo-reverse-trigger? Med Intensiva 2021; 45:e15-e17. [PMID: 34294564 DOI: 10.1016/j.medine.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 12/19/2019] [Indexed: 11/26/2022]
Affiliation(s)
- J A Benítez Lozano
- Unidad de Cuidados Intensivos, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - C de la Fuente Martos
- Unidad de Cuidados Intensivos, Hospital Regional Universitario Reina Sofía, Córdoba, Spain
| | - J M Serrano Simón
- Unidad de Cuidados Intensivos, Hospital Regional Universitario Reina Sofía, Córdoba, Spain.
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80
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Hsu FS, Huang SR, Huang CW, Huang CJ, Cheng YR, Chen CC, Hsiao J, Chen CW, Chen LC, Lai YC, Hsu BF, Lin NJ, Tsai WL, Wu YL, Tseng TL, Tseng CT, Chen YT, Lai F. Benchmarking of eight recurrent neural network variants for breath phase and adventitious sound detection on a self-developed open-access lung sound database-HF_Lung_V1. PLoS One 2021; 16:e0254134. [PMID: 34197556 PMCID: PMC8248710 DOI: 10.1371/journal.pone.0254134] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/20/2021] [Indexed: 01/15/2023] Open
Abstract
A reliable, remote, and continuous real-time respiratory sound monitor with automated respiratory sound analysis ability is urgently required in many clinical scenarios-such as in monitoring disease progression of coronavirus disease 2019-to replace conventional auscultation with a handheld stethoscope. However, a robust computerized respiratory sound analysis algorithm for breath phase detection and adventitious sound detection at the recording level has not yet been validated in practical applications. In this study, we developed a lung sound database (HF_Lung_V1) comprising 9,765 audio files of lung sounds (duration of 15 s each), 34,095 inhalation labels, 18,349 exhalation labels, 13,883 continuous adventitious sound (CAS) labels (comprising 8,457 wheeze labels, 686 stridor labels, and 4,740 rhonchus labels), and 15,606 discontinuous adventitious sound labels (all crackles). We conducted benchmark tests using long short-term memory (LSTM), gated recurrent unit (GRU), bidirectional LSTM (BiLSTM), bidirectional GRU (BiGRU), convolutional neural network (CNN)-LSTM, CNN-GRU, CNN-BiLSTM, and CNN-BiGRU models for breath phase detection and adventitious sound detection. We also conducted a performance comparison between the LSTM-based and GRU-based models, between unidirectional and bidirectional models, and between models with and without a CNN. The results revealed that these models exhibited adequate performance in lung sound analysis. The GRU-based models outperformed, in terms of F1 scores and areas under the receiver operating characteristic curves, the LSTM-based models in most of the defined tasks. Furthermore, all bidirectional models outperformed their unidirectional counterparts. Finally, the addition of a CNN improved the accuracy of lung sound analysis, especially in the CAS detection tasks.
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Affiliation(s)
- Fu-Shun Hsu
- Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan
- Department of Critical Care Medicine, Far Eastern Memorial Hospital, New Taipei, Taiwan
- Heroic Faith Medical Science Co., Ltd., Taipei, Taiwan
| | | | | | - Chao-Jung Huang
- Joint Research Center for Artificial Intelligence Technology and All Vista Healthcare, National Taiwan University, Taipei, Taiwan
| | - Yuan-Ren Cheng
- Heroic Faith Medical Science Co., Ltd., Taipei, Taiwan
- Department of Life Science, College of Life Science, National Taiwan University, Taipei, Taiwan
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | | | - Jack Hsiao
- HCC Healthcare Group, New Taipei, Taiwan
| | - Chung-Wei Chen
- Department of Critical Care Medicine, Far Eastern Memorial Hospital, New Taipei, Taiwan
| | - Li-Chin Chen
- Research Center for Information Technology Innovation, Academia Sinica, Taipei, Taiwan
| | - Yen-Chun Lai
- Heroic Faith Medical Science Co., Ltd., Taipei, Taiwan
| | - Bi-Fang Hsu
- Heroic Faith Medical Science Co., Ltd., Taipei, Taiwan
| | - Nian-Jhen Lin
- Heroic Faith Medical Science Co., Ltd., Taipei, Taiwan
- Division of Pulmonary Medicine, Far Eastern Memorial Hospital, New Taipei, Taiwan
| | - Wan-Ling Tsai
- Heroic Faith Medical Science Co., Ltd., Taipei, Taiwan
| | - Yi-Lin Wu
- Heroic Faith Medical Science Co., Ltd., Taipei, Taiwan
| | | | | | - Yi-Tsun Chen
- Heroic Faith Medical Science Co., Ltd., Taipei, Taiwan
| | - Feipei Lai
- Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan
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81
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Kuriyama A, Jackson JL. Neuromuscular blocking agents for acute respiratory distress syndrome. Hippokratia 2021. [DOI: 10.1002/14651858.cd014693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Akira Kuriyama
- Emergency and Critical Care Center; Kurashiki Central Hospital; Kurashiki Japan
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82
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Yuan X, Lu X, Chao Y, Beck J, Sinderby C, Xie J, Yang Y, Qiu H, Liu L. Neurally adjusted ventilatory assist as a weaning mode for adults with invasive mechanical ventilation: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:222. [PMID: 34187528 PMCID: PMC8240429 DOI: 10.1186/s13054-021-03644-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 06/16/2021] [Indexed: 11/29/2022]
Abstract
Background Prolonged ventilatory support is associated with poor clinical outcomes. Partial support modes, especially pressure support ventilation, are frequently used in clinical practice but are associated with patient–ventilation asynchrony and deliver fixed levels of assist. Neurally adjusted ventilatory assist (NAVA), a mode of partial ventilatory assist that reduces patient–ventilator asynchrony, may be an alternative for weaning. However, the effects of NAVA on weaning outcomes in clinical practice are unclear. Methods We searched PubMed, Embase, Medline, and Cochrane Library from 2007 to December 2020. Randomized controlled trials and crossover trials that compared NAVA and other modes were identified in this study. The primary outcome was weaning success which was defined as the absence of ventilatory support for more than 48 h. Summary estimates of effect using odds ratio (OR) for dichotomous outcomes and mean difference (MD) for continuous outcomes with accompanying 95% confidence interval (CI) were expressed. Results Seven studies (n = 693 patients) were included. Regarding the primary outcome, patients weaned with NAVA had a higher success rate compared with other partial support modes (OR = 1.93; 95% CI 1.12 to 3.32; P = 0.02). For the secondary outcomes, NAVA may reduce duration of mechanical ventilation (MD = − 2.63; 95% CI − 4.22 to − 1.03; P = 0.001) and hospital mortality (OR = 0.58; 95% CI 0.40 to 0.84; P = 0.004) and prolongs ventilator-free days (MD = 3.48; 95% CI 0.97 to 6.00; P = 0.007) when compared with other modes. Conclusions Our study suggests that the NAVA mode may improve the rate of weaning success compared with other partial support modes for difficult to wean patients. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03644-z.
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Affiliation(s)
- Xueyan Yuan
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Xinxing Lu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Yali Chao
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Jennifer Beck
- Department of Pediatrics, University of Toronto, Toronto, Canada.,Department of Critical Care, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada.,Institute for Biomedical Engineering and Science Technology (iBEST), Ryerson University and St-Michael's Hospital, Toronto, Canada
| | - Christer Sinderby
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Critical Care, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada.,Institute for Biomedical Engineering and Science Technology (iBEST), Ryerson University and St-Michael's Hospital, Toronto, Canada
| | - Jianfeng Xie
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China.
| | - Ling Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China.
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83
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Carteaux G, Parfait M, Combet M, Haudebourg AF, Tuffet S, Mekontso Dessap A. Patient-Self Inflicted Lung Injury: A Practical Review. J Clin Med 2021; 10:jcm10122738. [PMID: 34205783 PMCID: PMC8234933 DOI: 10.3390/jcm10122738] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/15/2021] [Accepted: 06/19/2021] [Indexed: 12/14/2022] Open
Abstract
Patients with severe lung injury usually have a high respiratory drive, resulting in intense inspiratory effort that may even worsen lung damage by several mechanisms gathered under the name “patient-self inflicted lung injury” (P-SILI). Even though no clinical study has yet demonstrated that a ventilatory strategy to limit the risk of P-SILI can improve the outcome, the concept of P-SILI relies on sound physiological reasoning, an accumulation of clinical observations and some consistent experimental data. In this review, we detail the main pathophysiological mechanisms by which the patient’s respiratory effort could become deleterious: excessive transpulmonary pressure resulting in over-distension; inhomogeneous distribution of transpulmonary pressure variations across the lung leading to cyclic opening/closing of nondependent regions and pendelluft phenomenon; increase in the transvascular pressure favoring the aggravation of pulmonary edema. We also describe potentially harmful patient-ventilator interactions. Finally, we discuss in a practical way how to detect in the clinical setting situations at risk for P-SILI and to what extent this recognition can help personalize the treatment strategy.
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Affiliation(s)
- Guillaume Carteaux
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
- INSERM U955, Institut Mondor de Recherche Biomédicale, F-94010 Créteil, France
- Correspondence:
| | - Mélodie Parfait
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
| | - Margot Combet
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
| | - Anne-Fleur Haudebourg
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
| | - Samuel Tuffet
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
- INSERM U955, Institut Mondor de Recherche Biomédicale, F-94010 Créteil, France
| | - Armand Mekontso Dessap
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
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84
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Etiology, incidence, and outcomes of patient-ventilator asynchrony in critically-ill patients undergoing invasive mechanical ventilation. Sci Rep 2021; 11:12390. [PMID: 34117278 PMCID: PMC8196026 DOI: 10.1038/s41598-021-90013-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/30/2021] [Indexed: 02/05/2023] Open
Abstract
Patient-ventilator asynchrony (PVA) is commonly encountered during mechanical ventilation of critically ill patients. Estimates of PVA incidence vary widely. Type, risk factors, and consequences of PVA remain unclear. We aimed to measure the incidence and identify types of PVA, characterize risk factors for development, and explore the relationship between PVA and outcome among critically ill, mechanically ventilated adult patients admitted to medical, surgical, and medical-surgical intensive care units in a large academic institution staffed with varying provider training background. A single center, retrospective cohort study of all adult critically ill patients undergoing invasive mechanical ventilation for ≥ 12 h. A total of 676 patients who underwent 696 episodes of mechanical ventilation were included. Overall PVA occurred in 170 (24%) episodes. Double triggering 92(13%) was most common, followed by flow starvation 73(10%). A history of smoking, and pneumonia, sepsis, or ARDS were risk factors for overall PVA and double triggering (all P < 0.05). Compared with volume targeted ventilation, pressure targeted ventilation decreased the occurrence of events (all P < 0.01). During volume controlled synchronized intermittent mandatory ventilation and pressure targeted ventilation, ventilator settings were associated with the incidence of overall PVA. The number of overall PVA, as well as double triggering and flow starvation specifically, were associated with worse outcomes and fewer hospital-free days (all P < 0.01). Double triggering and flow starvation are the most common PVA among critically ill, mechanically ventilated patients. Overall incidence as well as double triggering and flow starvation PVA specifically, portend worse outcome.
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85
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Sadek SH, El-kholy MM, Abdulmoez MS, El-Morshedy RM. Patient-ventilator asynchrony as a predictor of weaning failure in mechanically ventilated COPD patients. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2021. [PMCID: PMC8267513 DOI: 10.1186/s43168-021-00076-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Patient-ventilator asynchrony is a common problem in mechanically ventilated patients. It is associated with adverse effects including increased work of breathing, patient discomfort, increased need for sedation, prolonged mechanical ventilation, weaning difficulties, and weaning failure. The purpose of the present was to describe patient-ventilator asynchrony and its impact on weaning outcomes in mechanically ventilated chronic obstructive pulmonary disease (COPD) patients. Results One hundred mechanically ventilated COPD patients were enrolled in this prospective study. Weaning failure (need of NIV or reintubation within 48 h) was noticed in 27 (27%) patients while 73 (73%) patients had successful weaning. Patients with failed weaning had significantly higher asynchrony index (A.I) and ineffective trigger index (ITI) in comparison with those with successful weaning (7.69 ± 3.71, 3.46 ± 2.59 versus 6.27 ± 3.14, 2.47 ± 2.08, respectively; P value< 0.04). Data were expressed as mean ± standard deviation. Conclusion High asynchrony index and high ineffective trigger index may be early predictors of weaning failure in mechanically ventilated COPD patients.
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86
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Pan Q, Zhang L, Jia M, Pan J, Gong Q, Lu Y, Zhang Z, Ge H, Fang L. An interpretable 1D convolutional neural network for detecting patient-ventilator asynchrony in mechanical ventilation. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2021; 204:106057. [PMID: 33836375 DOI: 10.1016/j.cmpb.2021.106057] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/15/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND OBJECTIVE Patient-ventilator asynchrony (PVA) is the result of a mismatch between the need of patients and the assistance provided by the ventilator during mechanical ventilation. Because the poor interaction between the patient and the ventilator is associated with inferior clinical outcomes, effort should be made to identify and correct their occurrence. Deep learning has shown promising ability in PVA detection; however, lack of network interpretability hampers its application in clinic. METHODS We proposed an interpretable one-dimensional convolutional neural network (1DCNN) to detect four most manifestation types of PVA (double triggering, ineffective efforts during expiration, premature cycling and delayed cycling) under pressure control ventilation mode and pressure support ventilation mode. A global average pooling (GAP) layer was incorporated with the 1DCNN model to highlight the sections of the respiratory waveform the model focused on when making a classification. Dilation convolution and batch normalization were introduced to the 1DCNN model for compensating the reduction of performance caused by the GAP layer. RESULTS The proposed interpretable 1DCNN exhibited comparable performance with the state-of-the-art deep learning model in PVA detection. The F1 scores for the detection of four types of PVA under pressure control ventilation and pressure support ventilation modes were greater than 0.96. The critical sections of the waveform used to detect PVA were highlighted, and found to be well consistent with the understanding of the respective type of PVA by experts. CONCLUSIONS The findings suggest that the proposed 1DCNN can help detect PVA, and enhance the interpretability of the classification process to help clinicians better understand the results obtained from deep learning technology.
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Affiliation(s)
- Qing Pan
- College of Information Engineering, Zhejiang University of Technology, Liuhe Rd. 288, Hangzhou 310023, China
| | - Lingwei Zhang
- College of Information Engineering, Zhejiang University of Technology, Liuhe Rd. 288, Hangzhou 310023, China
| | - Mengzhe Jia
- College of Information Engineering, Zhejiang University of Technology, Liuhe Rd. 288, Hangzhou 310023, China
| | - Jie Pan
- College of Information Engineering, Zhejiang University of Technology, Liuhe Rd. 288, Hangzhou 310023, China
| | - Qiang Gong
- College of Information Engineering, Zhejiang University of Technology, Liuhe Rd. 288, Hangzhou 310023, China
| | - Yunfei Lu
- College of Information Engineering, Zhejiang University of Technology, Liuhe Rd. 288, Hangzhou 310023, China
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Qingchun East Rd. 3, Hangzhou 310016, China
| | - Huiqing Ge
- Department of Respiratory Care, Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Qingchun East Rd. 3, Hangzhou 310016, China.
| | - Luping Fang
- College of Information Engineering, Zhejiang University of Technology, Liuhe Rd. 288, Hangzhou 310023, China.
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87
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Coppola S, Pozzi T, Chiumello D. Reverse trigger in COVID-19 ARDS. Minerva Anestesiol 2021; 87:1271-1272. [PMID: 34036772 DOI: 10.23736/s0375-9393.21.15798-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Silvia Coppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy
| | - Tommaso Pozzi
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Davide Chiumello
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy - .,Department of Health Sciences, University of Milan, Milan, Italy.,Coordinated Research Center on Respiratory Failure, University of Milan, Milan, Italy
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88
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Alqahtani JS. Patient–ventilator asynchrony in Saudi Arabia: Where we stand? World J Crit Care Med 2021; 10:58-60. [PMID: 34046311 PMCID: PMC8131934 DOI: 10.5492/wjccm.v10.i3.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/13/2021] [Accepted: 03/08/2021] [Indexed: 02/06/2023] Open
Abstract
Patient–ventilator asynchrony in Saudi Arabia practices is common, and more emphasis on how to mitigate such a clinical problem is needed. This letter is intended to shed the light on the current national evidence of patient–ventilator asynchrony and how to step ahead for better patients' ventilation management.
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Affiliation(s)
- Jaber S Alqahtani
- UCL Respiratory, University College London, London WC1E 6BT, United Kingdom
- Department of Respiratory Care, Prince Sultan Military College of Health Sciences, Dammam 34313, Saudi Arabia
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89
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Oto B, Annesi J, Foley RJ. Patient-ventilator dyssynchrony in the intensive care unit: A practical approach to diagnosis and management. Anaesth Intensive Care 2021; 49:86-97. [PMID: 33906464 DOI: 10.1177/0310057x20978981] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patient-ventilator dyssynchrony or asynchrony occurs when, for any parameter of respiration, discordance exists between the patient's spontaneous effort and the ventilator's provided support. If not recognised, it may promote oversedation, prolong the duration of mechanical ventilation, create risk for lung injury, and generally confuse the clinical picture. Seven forms of dyssynchrony are common: (a) ineffective triggering; (b) autotriggering; (c) inadequate flow; (d) too much flow; (e) premature cycling; (f) delayed cycling; and (g) peak pressure apnoea. 'Reverse triggering' also occurs and may mimic premature cycling. Correct diagnosis of these phenomena often permits management by simple ventilator optimisation rather than by less desirable measures.
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Affiliation(s)
- Brandon Oto
- Adult Critical Care, UConn Health, Farmington, USA
| | - Janet Annesi
- Respiratory Therapy Department, UConn Health, Farmington, USA
| | - Raymond J Foley
- Division of Pulmonary, Critical Care, and Sleep Medicine, UConn Health, Farmington, USA
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90
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Comparative effects of neurally adjusted ventilatory assist and variable pressure support on lung and diaphragmatic function in a model of acute respiratory distress syndrome: A randomised animal study. Eur J Anaesthesiol 2021; 38:32-40. [PMID: 32657806 DOI: 10.1097/eja.0000000000001261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Variable assisted mechanical ventilation has been shown to improve lung function and reduce lung injury. However, differences between extrinsic and intrinsic variability are unknown. OBJECTIVE To investigate the effects of neurally adjusted ventilatory assist (NAVA, intrinsic variability), variable pressure support ventilation (Noisy PSV, extrinsic variability) and conventional pressure-controlled ventilation (PCV) on lung and diaphragmatic function and damage in experimental acute respiratory distress syndrome (ARDS). DESIGN Randomised controlled animal study. SETTING University Hospital Research Facility. SUBJECTS A total of 24 juvenile female pigs. INTERVENTIONS ARDS was induced by repetitive lung lavage and injurious ventilation. Animals were randomly assigned to 24 h of either: 1) NAVA, 2) Noisy PSV or 3) PCV (n=8 per group). Mechanical ventilation settings followed the ARDS Network recommendations. MEASUREMENTS The primary outcome was histological lung damage. Secondary outcomes were respiratory variables and patterns, subject-ventilator asynchrony (SVA), pulmonary and diaphragmatic biomarkers, as well as diaphragmatic muscle atrophy and myosin isotypes. RESULTS Global alveolar damage did not differ between groups, but NAVA resulted in less interstitial oedema in dorsal lung regions than Noisy PSV. Gas exchange and SVA incidence did not differ between groups. Compared with Noisy PSV, NAVA generated higher coefficients of variation of tidal volume and respiratory rate. During NAVA, only 40.4% of breaths were triggered by the electrical diaphragm signal. The IL-8 concentration in lung tissue was lower after NAVA compared with PCV and Noisy PSV, whereas Noisy PSV yielded lower type III procollagen mRNA expression than NAVA and PCV. Diaphragmatic muscle fibre diameters were smaller after PCV compared with assisted modes, whereas expression of myosin isotypes did not differ between groups. CONCLUSION Noisy PSV and NAVA did not reduce global lung injury compared with PCV but affected different biomarkers and attenuated diaphragmatic atrophy. NAVA increased the respiratory variability; however, NAVA yielded a similar SVA incidence as Noisy PSV. TRIAL REGISTRATION This trial was registered and approved by the Landesdirektion Dresden, Germany (AZ 24-9168.11-1/2012-2).
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Abstract
PURPOSE OF REVIEW A growing evidence shows that injurious spontaneous breathing, either too weak or too strong, may injure lung and diaphragm. The purpose of review is to understand why we need monitoring for safe spontaneous breathing, and to know the target value of each monitoring to preserve safe spontaneous breathing during assisted ventilation. RECENT FINDINGS Lung protection sometimes goes counter to diaphragm protection. For instance, silence of respiratory muscle activity is necessary to minimize lung injury from vigorous spontaneous effort in acute respiratory distress syndrome, but it may also have a risk of diaphragm atrophy. Thus, our current goal is to preserve spontaneous breathing activity at modest level during assisted ventilation. To achieve this goal, several monitoring/techniques are now available at the bedside (e.g., plateau pressure measurement, airway occlusion pressure, end-expiratory airway occlusion, esophageal balloon manometry, electrical impedance tomography). The target value of each monitoring is vigorously being investigated, facilitating 'safe' spontaneous breathing effort from the perspective of lung and diaphragm protection. SUMMARY We summarize why we need monitoring for safe spontaneous breathing during assisted ventilation and what the target value of each monitoring is to facilitate 'safe' spontaneous breathing during assisted ventilation.
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Chen TJ, Chung YW, Chen PY, Hu SH, Chang CC, Hsieh SH, Wang BC, Chiu HY. Effects of daily sedation interruption in intensive care unit patients undergoing mechanical ventilation: A meta-analysis of randomized controlled trials. Int J Nurs Pract 2021; 28:e12948. [PMID: 33881193 DOI: 10.1111/ijn.12948] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Revised: 02/10/2021] [Accepted: 03/21/2021] [Indexed: 12/25/2022]
Abstract
AIM This study aimed to assess the effects of daily sedation interruption on the mechanical ventilation duration and relevant outcomes in mechanically ventilated patients in the intensive care unit (ICU). BACKGROUND Previously, three meta-analyses on the association of daily sedation interruption with the mechanical ventilation duration have reported conflicting findings, and these did not support current guideline recommendations that daily sedation interruption can be routinely used in mechanically ventilated adult ICU patients. DESIGN This was a systematic review and meta-analysis of randomized controlled studies. DATA SOURCES Data were from PubMed, Embase, Cochrane Library, CINAHL, ProQuest dissertation and theses, Airiti Library, China National Knowledge Infrastructure, Wanfang Data Chinese, Science Direct and PsycINFO databases. REVIEW METHODS Two reviewers independently assessed, extracted and appraised the included studies. Then, pooled estimates were calculated using a random-effects model. RESULTS In total, 45 studies involving 5493 participants were included. Compared with controls, daily sedation interruption significantly reduced the mechanical ventilation duration, ICU stay length, sedation duration, and tracheostomy and ventilator-associated pneumonia risks (all p ≤ 0.001). Moreover, the Acute Physiology and Chronic Health Evaluation II score and study quality were significant moderators. CONCLUSION Daily sedation interruption could substantially reduce the duration of mechanical ventilation, particularly when it was applied to patients with high disease severity. SUMMARY STATEMENT What is already known about this topic? Daily sedation interruption has been associated with reductions in excessive sedation and excessive use of sedative agents. The findings on the effects of daily sedation interruption on the mechanical ventilation duration have been inconsistent. What this paper adds? Daily sedation interruption could effectively reduce the mechanical ventilation duration, intensive care unit stay length, sedation duration, and tracheostomy and ventilator-associated pneumonia risks in intensive care unit patients. Applying daily sedation interruption to patients with high disease severity yielded a larger reduction in the mechanical ventilation duration. The implications of this paper: There is a need to adopt daily sedation interruption as routine care to reduce the mechanical ventilation duration, especially in higher disease severity population.
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Affiliation(s)
- Ting-Jhen Chen
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Yi-Wei Chung
- Department of Cardiology, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
| | - Pin-Yuan Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Sophia H Hu
- Department of Nursing, School of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chuen-Chau Chang
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei, Taiwan
| | - Shu-Hua Hsieh
- Department of Nursing, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Bo-Cyuan Wang
- Department of Nursing, New Taipei City Municipal Tucheng Hospital, New Taipei City, Taiwan
| | - Hsiao-Yean Chiu
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
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93
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Clusters of Double Triggering Impact Clinical Outcomes: Insights From the EPIdemiology of Patient-Ventilator aSYNChrony (EPISYNC) Cohort Study. Crit Care Med 2021; 49:1460-1469. [PMID: 33883458 DOI: 10.1097/ccm.0000000000005029] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To measure the impact of clusters of double triggering on clinical outcomes. DESIGN Prospective cohort study. SETTING Respiratory ICU in Brazil. PATIENTS Adult patients under recent mechanical ventilation and with expectation of mechanical ventilation for more than 24 hours after enrollment. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We used a dedicated software to analyze ventilator waveforms throughout the entire period of mechanical ventilation and detect double triggering. We defined a cluster of double triggering as a period of time containing at least six double triggering events in a 3-minute period. Patients were followed until hospital discharge. We addressed the association between the presence and the duration of clusters with clinical outcomes. A total of 103 patients were enrolled in the study and 90 (87%) had at least one cluster of double triggering. The median number of clusters per patient was 19 (interquartile range, 6-41), with a median duration of 8 minutes (6-12 min). Compared with patients who had no clusters, patients with at least one cluster had longer duration of mechanical ventilation (7 d [4-11 d] vs 2 d [2-3 d]) and ICU length of stay (9 d [7-16 d] vs 13 d [2-8 d]). Thirty-three patients had high cumulative duration of clusters of double triggering (≥ 12 hr), and it was associated with longer duration of mechanical ventilation, fewer ventilator-free days, and longer ICU length of stay. Adjusted by duration of mechanical ventilation and severity of illness, high cumulative duration of clusters was associated with shorter survival at 28 days (hazard ratio, 2.09 d; 95% CI, 1.04-4.19 d). CONCLUSIONS Clusters of double triggering are common and were associated with worse clinical outcomes. Patients who had a high cumulative duration of clusters had fewer ventilator-free days, longer duration of mechanical ventilation, longer ICU length of stay, and shorter survival than patients with low cumulative duration of cluster.
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Patient–Ventilator Interaction Testing Using the Electromechanical Lung Simulator xPULM™ during V/A-C and PSV Ventilation Mode. APPLIED SCIENCES-BASEL 2021. [DOI: 10.3390/app11093745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
During mechanical ventilation, a disparity between flow, pressure and volume demands of the patient and the assistance delivered by the mechanical ventilator often occurs. This paper introduces an alternative approach of simulating and evaluating patient–ventilator interactions with high fidelity using the electromechanical lung simulator xPULM™. The xPULM™ approximates respiratory activities of a patient during alternating phases of spontaneous breathing and apnea intervals while connected to a mechanical ventilator. Focusing on different triggering events, volume assist-control (V/A-C) and pressure support ventilation (PSV) modes were chosen to test patient–ventilator interactions. In V/A-C mode, a double-triggering was detected every third breathing cycle, leading to an asynchrony index of 16.67%, which is classified as severe. This asynchrony causes a significant increase of peak inspiratory pressure (7.96 ± 6.38 vs. 11.09 ± 0.49 cmH2O, p < 0.01)) and peak expiratory flow (−25.57 ± 8.93 vs. 32.90 ± 0.54 L/min, p < 0.01) when compared to synchronous phases of the breathing simulation. Additionally, events of premature cycling were observed during PSV mode. In this mode, the peak delivered volume during simulated spontaneous breathing phases increased significantly (917.09 ± 45.74 vs. 468.40 ± 31.79 mL, p < 0.01) compared to apnea phases. Various dynamic clinical situations can be approximated using this approach and thereby could help to identify undesired patient–ventilation interactions in the future. Rapidly manufactured ventilator systems could also be tested using this approach.
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96
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Tilmont A, Coiffard B, Yoshida T, Daviet F, Baumstarck K, Brioude G, Hraiech S, Forel JM, Roch A, Brochard L, Papazian L, Guervilly C. Oesophageal pressure as a surrogate of pleural pressure in mechanically ventilated patients. ERJ Open Res 2021; 7:00646-2020. [PMID: 33718491 PMCID: PMC7938048 DOI: 10.1183/23120541.00646-2020] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 12/02/2020] [Indexed: 11/18/2022] Open
Abstract
Background Oesophageal pressure (Poes) is used to approximate pleural pressure (Ppl) and therefore to estimate transpulmonary pressure (PL). We aimed to compare oesophageal and regional pleural pressures and to calculate transpulmonary pressures in a prospective physiological study on lung transplant recipients during their stay in the intensive care unit of a tertiary university hospital. Methods Lung transplant recipients receiving invasive mechanical ventilation and monitored by oesophageal manometry and dependent and nondependent pleural catheters were investigated during the post-operative period. We performed simultaneous short-time measurements and recordings of oesophageal manometry and pleural pressures. Expiratory and inspiratory PL were computed by subtracting regional Ppl or Poes from airway pressure; inspiratory PL was also calculated with the elastance ratio method. Results 16 patients were included. Among them, 14 were analysed. Oesophageal pressures correlated with dependent and nondependent pleural pressures during expiration (R2=0.71, p=0.005 and R2=0.77, p=0.001, respectively) and during inspiration (R2=0.66 for both, p=0.01 and p=0.014, respectively). PL values calculated using Poes were close to those obtained from the dependent pleural catheter but higher than those obtained from the nondependent pleural catheter both during expiration and inspiration. Conclusions In ventilated lung transplant recipients, oesophageal manometry is well correlated with pleural pressure. The absolute value of Poes is higher than Ppl of nondependent lung regions and could therefore underestimate the highest level of lung stress in those at high risk of overinflation. During controlled ventilation without respiratory muscle activity, absolute oesophageal pressure is higher than the pleural pressure of the nondependent lung regions and could therefore underestimate the highest level of lung stress in that lunghttps://bit.ly/3a95CUh
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Affiliation(s)
- Antoine Tilmont
- Médecine Intensive Réanimation, Hôpital Nord, AP-HM, Marseille, France.,Faculté de Médecine, Centre d'Etudes et de Recherches sur les Services de Santé et Qualité de Vie EA 3279, Aix-Marseille Université, Marseille, France
| | - Benjamin Coiffard
- Médecine Intensive Réanimation, Hôpital Nord, AP-HM, Marseille, France.,Faculté de Médecine, Centre d'Etudes et de Recherches sur les Services de Santé et Qualité de Vie EA 3279, Aix-Marseille Université, Marseille, France
| | - Takeshi Yoshida
- Dept of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan.,Pleural Pressure Working Group (PLUG) - Acute Respiratory Failure Section of the European Society of Intensive Care Medicine, Brussels, Belgium
| | - Florence Daviet
- Médecine Intensive Réanimation, Hôpital Nord, AP-HM, Marseille, France.,Faculté de Médecine, Centre d'Etudes et de Recherches sur les Services de Santé et Qualité de Vie EA 3279, Aix-Marseille Université, Marseille, France
| | - Karine Baumstarck
- Faculté de Médecine, Centre d'Etudes et de Recherches sur les Services de Santé et Qualité de Vie EA 3279, Aix-Marseille Université, Marseille, France
| | - Geoffrey Brioude
- Dept of Thoracic Surgery and Oesophageal Diseases, Hôpital Nord, AP-HM, Marseille, France
| | - Sami Hraiech
- Médecine Intensive Réanimation, Hôpital Nord, AP-HM, Marseille, France.,Faculté de Médecine, Centre d'Etudes et de Recherches sur les Services de Santé et Qualité de Vie EA 3279, Aix-Marseille Université, Marseille, France
| | - Jean-Marie Forel
- Médecine Intensive Réanimation, Hôpital Nord, AP-HM, Marseille, France.,Faculté de Médecine, Centre d'Etudes et de Recherches sur les Services de Santé et Qualité de Vie EA 3279, Aix-Marseille Université, Marseille, France
| | - Antoine Roch
- Médecine Intensive Réanimation, Hôpital Nord, AP-HM, Marseille, France.,Service des Urgences, Hôpital Nord, AP-HM, Marseille, France
| | - Laurent Brochard
- Pleural Pressure Working Group (PLUG) - Acute Respiratory Failure Section of the European Society of Intensive Care Medicine, Brussels, Belgium.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Laurent Papazian
- Médecine Intensive Réanimation, Hôpital Nord, AP-HM, Marseille, France.,Pleural Pressure Working Group (PLUG) - Acute Respiratory Failure Section of the European Society of Intensive Care Medicine, Brussels, Belgium
| | - Christophe Guervilly
- Médecine Intensive Réanimation, Hôpital Nord, AP-HM, Marseille, France.,Pleural Pressure Working Group (PLUG) - Acute Respiratory Failure Section of the European Society of Intensive Care Medicine, Brussels, Belgium
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Patout M, Fresnel E, Lujan M, Rabec C, Carlucci A, Razakamanantsoa L, Kerfourn A, Nunes H, Tandjaoui-Lambiotte Y, Cuvelier A, Muir JF, Lalmoda C, Langevin B, Sayas J, Gonzalez-Bermejo J, Janssens JP. Recommended Approaches to Minimize Aerosol Dispersion of SARS-CoV-2 During Noninvasive Ventilatory Support Can Cause Ventilator Performance Deterioration: A Benchmark Comparative Study. Chest 2021; 160:175-186. [PMID: 33667491 PMCID: PMC7921720 DOI: 10.1016/j.chest.2021.02.047] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/28/2021] [Accepted: 02/18/2021] [Indexed: 01/07/2023] Open
Abstract
Background SARS-CoV-2 aerosolization during noninvasive positive-pressure ventilation may endanger health care professionals. Various circuit setups have been described to reduce virus aerosolization. However, these setups may alter ventilator performance. Research Question What are the consequences of the various suggested circuit setups on ventilator efficacy during CPAP and noninvasive ventilation (NIV)? Study Design and Methods Eight circuit setups were evaluated on a bench test model that consisted of a three-dimensional printed head and an artificial lung. Setups included a dual-limb circuit with an oronasal mask, a dual-limb circuit with a helmet interface, a single-limb circuit with a passive exhalation valve, three single-limb circuits with custom-made additional leaks, and two single-limb circuits with active exhalation valves. All setups were evaluated during NIV and CPAP. The following variables were recorded: the inspiratory flow preceding triggering of the ventilator, the inspiratory effort required to trigger the ventilator, the triggering delay, the maximal inspiratory pressure delivered by the ventilator, the tidal volume generated to the artificial lung, the total work of breathing, and the pressure-time product needed to trigger the ventilator. Results With NIV, the type of circuit setup had a significant impact on inspiratory flow preceding triggering of the ventilator (P < .0001), the inspiratory effort required to trigger the ventilator (P < .0001), the triggering delay (P < .0001), the maximal inspiratory pressure (P < .0001), the tidal volume (P = .0008), the work of breathing (P < .0001), and the pressure-time product needed to trigger the ventilator (P < .0001). Similar differences and consequences were seen with CPAP as well as with the addition of bacterial filters. Best performance was achieved with a dual-limb circuit with an oronasal mask. Worst performance was achieved with a dual-limb circuit with a helmet interface. Interpretation Ventilator performance is significantly impacted by the circuit setup. A dual-limb circuit with oronasal mask should be used preferentially.
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Affiliation(s)
- Maxime Patout
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service des Pathologies du Sommeil (Département R3S), F-75013 Paris, France; Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, France; Respiratory Department, Avicenne Hospital, AP-HP, Bobigny, France; Normandie University, UNIRouen, EA3830-GRHV, Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France.
| | - Emeline Fresnel
- Normandie University, UNIRouen, EA3830-GRHV, Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France; Kernel Biomedical, Bois-Guillaume, France
| | - Manuel Lujan
- Pneumology Department, Corporació Sanitaria Parc Taulí, Sabadell, Barcelona, Spain
| | - Claudio Rabec
- Pulmonary Department and Respiratory Critical Care Unit, University Hospital Dijon, Dijon, France; Fédération ANTADIR, Paris, France
| | - Annalisa Carlucci
- Pulmonary Rehabilitation, Istituti Clinici Scientifici Maugeri, Pavia, Italy; Department of Medicine, University of Insubria Varese, Como, Italy
| | - Léa Razakamanantsoa
- Normandie University, UNIRouen, EA3830-GRHV, Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France
| | - Adrien Kerfourn
- Normandie University, UNIRouen, EA3830-GRHV, Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France; Kernel Biomedical, Bois-Guillaume, France
| | - Hilario Nunes
- Respiratory Department, Avicenne Hospital, AP-HP, Bobigny, France; INSERM U1272, "Hypoxia and the Lung", Paris 13 University, Bobigny, France
| | - Yacine Tandjaoui-Lambiotte
- INSERM U1272, "Hypoxia and the Lung", Paris 13 University, Bobigny, France; Intensive Care Unit, Avicenne Hospital, AP-HP, Bobigny, France
| | | | - Jean-François Muir
- Normandie University, UNIRouen, EA3830-GRHV, Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France; Fédération ANTADIR, Paris, France
| | - Cristina Lalmoda
- Pneumology Department, Corporació Sanitaria Parc Taulí, Sabadell, Barcelona, Spain
| | - Bruno Langevin
- Réanimation, Pôle Soins Aigus, Centre Hospitalier Alès, Alès, France
| | - Javier Sayas
- Servicio de Neumología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Jesus Gonzalez-Bermejo
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, France; AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), F-75013 Paris, France
| | - Jean-Paul Janssens
- Division of Pulmonary Diseases, Geneva University Hospitals (HUG), Geneva, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland
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See KC, Sahagun J, Cove M, Sum CL, Garcia B, Chanco D, Misanes S, Abastillas E, Taculod J. Managing patient-ventilator asynchrony with a twice-daily screening protocol: A retrospective cohort study. Aust Crit Care 2021; 34:539-546. [PMID: 33632607 DOI: 10.1016/j.aucc.2020.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 09/26/2020] [Accepted: 11/01/2020] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Severe patient-ventilator asynchrony (PVA) might be associated with prolonged mechanical ventilation and mortality. It is unknown if systematic screening and application of conventional methods for PVA management can modify these outcomes. We therefore constructed a twice-daily bedside PVA screening and management protocol and investigated its effect on patient outcomes. MATERIALS AND METHODS A retrospective cohort study of patients who were intubated in the emergency department and directly admitted to the medical intensive care unit (ICU). In phase 1 (6 months; August 2016 to January 2017), patients received usual care comprising lung protective ventilation and moderate analgesia/sedation. In phase 2 (6 months; February 2017 to July 2017), patients were additionally managed with a PVA protocol on ICU admission and twice daily (7 am, 7 pm). RESULTS A total of 280 patients (160 in phase 1, 120 in phase 2) were studied (age = 64.5 ± 21.4 years, 107 women [38.2%], Acute Physiology and Chronic Health Evaluation II score = 27.1 ± 8.5, 271 [96.8%] on volume assist-control ventilation initially). Phase 2 patients had lower hospital mortality than phase 1 patients (20.0% versus 34.4%, respectively, P = 0.011), even after adjustment for age and Acute Physiology and Chronic Health Evaluation II scores (odds ratio = 0.46, 95% confidence interval = 0.25-0.84). CONCLUSIONS Application of a bedside PVA protocol for mechanically ventilated patients on ICU admission and twice daily was associated with decreased hospital mortality. There was however no association with sedation-free days or mechanical ventilation-free days through day 28 or length of hospital stay.
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Affiliation(s)
- Kay Choong See
- Division of Respiratory & Critical Care Medicine, Department of Medicine, National University Health System, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Juliet Sahagun
- Division of Critical Care - Respiratory Therapy, National University Hospital, Singapore.
| | - Matthew Cove
- Division of Respiratory & Critical Care Medicine, Department of Medicine, National University Health System, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Chew Lai Sum
- Department of Nursing, National University Hospital, Singapore.
| | - Bimbo Garcia
- Division of Critical Care - Respiratory Therapy, National University Hospital, Singapore.
| | - David Chanco
- Division of Critical Care - Respiratory Therapy, National University Hospital, Singapore.
| | - Sherill Misanes
- Division of Critical Care - Respiratory Therapy, National University Hospital, Singapore.
| | - Emily Abastillas
- Division of Critical Care - Respiratory Therapy, National University Hospital, Singapore.
| | - Juvel Taculod
- Division of Critical Care - Respiratory Therapy, National University Hospital, Singapore.
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Pham T, Montanya J, Telias I, Piraino T, Magrans R, Coudroy R, Damiani LF, Mellado Artigas R, Madorno M, Blanch L, Brochard L. Automated detection and quantification of reverse triggering effort under mechanical ventilation. Crit Care 2021; 25:60. [PMID: 33588912 PMCID: PMC7883535 DOI: 10.1186/s13054-020-03387-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/12/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Reverse triggering (RT) is a dyssynchrony defined by a respiratory muscle contraction following a passive mechanical insufflation. It is potentially harmful for the lung and the diaphragm, but its detection is challenging. Magnitude of effort generated by RT is currently unknown. Our objective was to validate supervised methods for automatic detection of RT using only airway pressure (Paw) and flow. A secondary objective was to describe the magnitude of the efforts generated during RT. METHODS We developed algorithms for detection of RT using Paw and flow waveforms. Experts having Paw, flow and esophageal pressure (Pes) assessed automatic detection accuracy by comparison against visual assessment. Muscular pressure (Pmus) was measured from Pes during RT, triggered breaths and ineffective efforts. RESULTS Tracings from 20 hypoxemic patients were used (mean age 65 ± 12 years, 65% male, ICU survival 75%). RT was present in 24% of the breaths ranging from 0 (patients paralyzed or in pressure support ventilation) to 93.3%. Automatic detection accuracy was 95.5%: sensitivity 83.1%, specificity 99.4%, positive predictive value 97.6%, negative predictive value 95.0% and kappa index of 0.87. Pmus of RT ranged from 1.3 to 36.8 cmH20, with a median of 8.7 cmH20. RT with breath stacking had the highest levels of Pmus, and RTs with no breath stacking were of similar magnitude than pressure support breaths. CONCLUSION An automated detection tool using airway pressure and flow can diagnose reverse triggering with excellent accuracy. RT generates a median Pmus of 9 cmH2O with important variability between and within patients. TRIAL REGISTRATION BEARDS, NCT03447288.
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Affiliation(s)
- Tài Pham
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada. .,Interdepartmental Division of Critical Care Medicine, University of Toronto, 209 Victoria St, Toronto, ON, M5B 1T8, Canada. .,Université Paris-Saclay, AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, FHU SEPSIS, Groupe de recherche clinique CARMAS, Le Kremlin-Bicêtre, France.
| | | | - Irene Telias
- grid.415502.7Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 30 Bond St, Toronto, ON M5B 1W8 Canada ,grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, 209 Victoria St, Toronto, ON M5B 1T8 Canada ,grid.231844.80000 0004 0474 0428Division of Respirology, Department of Medicine, University Health Network, Toronto, Canada ,grid.492573.e0000 0004 6477 6457Sinai Health System, Toronto, Canada
| | - Thomas Piraino
- grid.415502.7St. Michael’s Hospital, Unity Health Toronto, Toronto, Canada ,grid.25073.330000 0004 1936 8227Division of Critical Care, Department of Anesthesia, McMaster University, Hamilton, Canada
| | | | - Rémi Coudroy
- grid.415502.7Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 30 Bond St, Toronto, ON M5B 1W8 Canada ,grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, 209 Victoria St, Toronto, ON M5B 1T8 Canada ,grid.411162.10000 0000 9336 4276Médecine Intensive Réanimation, CHU de Poitiers, Poitiers, France ,grid.11166.310000 0001 2160 6368INSERM CIC 1402, Groupe ALIVE, Université de Poitiers, Poitiers, France
| | - L. Felipe Damiani
- grid.415502.7Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 30 Bond St, Toronto, ON M5B 1W8 Canada ,grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, 209 Victoria St, Toronto, ON M5B 1T8 Canada ,grid.7870.80000 0001 2157 0406Departamento Ciencias de la Salud, Carrera de Kinesiología, Faculdad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Ricard Mellado Artigas
- grid.415502.7Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 30 Bond St, Toronto, ON M5B 1W8 Canada ,grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, 209 Victoria St, Toronto, ON M5B 1T8 Canada ,grid.410458.c0000 0000 9635 9413Surgical ICU, Department of Anesthesia, Hospital Clínic, Barcelona, Spain
| | - Matías Madorno
- grid.441574.70000000090137393Instituto Tecnológico de Buenos Aires (ITBA), Buenos Aires, Argentina
| | - Lluis Blanch
- grid.7080.f0000 0001 2296 0625Critical Care Center, Hospital Universitari Parc Taulí, Institut D’Investigació I Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain ,grid.413448.e0000 0000 9314 1427Biomedical Research Networking Center in Respiratory Disease (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Laurent Brochard
- grid.415502.7Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 30 Bond St, Toronto, ON M5B 1W8 Canada ,grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, 209 Victoria St, Toronto, ON M5B 1T8 Canada
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Abstract
Acute respiratory distress syndrome (ARDS) is a fatal condition with insufficiently clarified etiology. Supportive care for severe hypoxemia remains the mainstay of essential interventions for ARDS. In recent years, adequate ventilation to prevent ventilator-induced lung injury (VILI) and patient self-inflicted lung injury (P-SILI) as well as lung-protective mechanical ventilation has an increasing attention in ARDS. Ventilation-perfusion mismatch may augment severe hypoxemia and inspiratory drive and consequently induce P-SILI. Respiratory drive and effort must also be carefully monitored to prevent P-SILI. Airway occlusion pressure (P0.1) and airway pressure deflection during an end-expiratory airway occlusion (Pocc) could be easy indicators to evaluate the respiratory drive and effort. Patient-ventilator dyssynchrony is a time mismatching between patient’s effort and ventilator drive. Although it is frequently unrecognized, dyssynchrony can be associated with poor clinical outcomes. Dyssynchrony includes trigger asynchrony, cycling asynchrony, and flow delivery mismatch. Ventilator-induced diaphragm dysfunction (VIDD) is a form of iatrogenic injury from inadequate use of mechanical ventilation. Excessive spontaneous breathing can lead to P-SILI, while excessive rest can lead to VIDD. Optimal balance between these two manifestations is probably associated with the etiology and severity of the underlying pulmonary disease. High-flow nasal cannula (HFNC) and non-invasive positive pressure ventilation (NPPV) are non-invasive techniques for supporting hypoxemia. While they are beneficial as respiratory supports in mild ARDS, there can be a risk of delaying needed intubation. Mechanical ventilation and ECMO are applied for more severe ARDS. However, as with HFNC/NPPV, inappropriate assessment of breathing workload potentially has a risk of delaying the timing of shifting from ventilator to ECMO. Various methods of oxygen administration in ARDS are important. However, it is also important to evaluate whether they adequately reduce the breathing workload and help to improve ARDS.
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Affiliation(s)
- Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
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