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Sindelar R, McKinney RL, Wallström L, Keszler M. Proportional assist and neurally adjusted ventilation: Clinical knowledge and future trials in newborn infants. Pediatr Pulmonol 2021; 56:1841-1849. [PMID: 33721418 DOI: 10.1002/ppul.25354] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 02/16/2021] [Accepted: 03/02/2021] [Indexed: 11/07/2022]
Abstract
Different types of patient triggered ventilator modes have become the mainstay of ventilation in term and preterm newborn infants. Maintaining spontaneous breathing has allowed for earlier weaning and the additive effects of respiratory efforts combined with pre-set mechanical inflations have reduced mean airway pressures, both of which are important components in trying to avoid lung injury and promote normal lung development. New sophisticated modes of assisted ventilation have been developed during the last decades where the control of ventilator support is turned over to the patient. The ventilator detects the respiratory effort and adjusts ventilatory assistance proportionally to each phase of the respiratory cycle, thus enabling the patient to have full control of the start, the duration and the amount of ventilatory assistance. In this paper we will review the literature on the ventilatory modes of proportional assist ventilation and neurally adjusted ventilatory assistance, examine the different ways the signals are analyzed, propose future studies, and suggest ways to apply these modes in the clinical environment.
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Affiliation(s)
- Richard Sindelar
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Robin L McKinney
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Linda Wallström
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Martin Keszler
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, Rhode Island
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Mortamet G, Larouche A, Ducharme-Crevier L, Fléchelles O, Constantin G, Essouri S, Pellerin-Leblanc AA, Beck J, Sinderby C, Jouvet P, Emeriaud G. Patient-ventilator asynchrony during conventional mechanical ventilation in children. Ann Intensive Care 2017; 7:122. [PMID: 29264742 PMCID: PMC5738329 DOI: 10.1186/s13613-017-0344-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 12/13/2017] [Indexed: 11/22/2022] Open
Abstract
Background We aimed (1) to describe the characteristics of patient–ventilator asynchrony in a population of critically ill children, (2) to describe the risk factors associated with patient–ventilator asynchrony, and (3) to evaluate the association between patient–ventilator asynchrony and ventilator-free days at day 28. Methods In this single-center prospective study, consecutive children admitted to the PICU and mechanically ventilated for at least 24 h were included. Patient–ventilator asynchrony was analyzed by comparing the ventilator pressure curve and the electrical activity of the diaphragm (Edi) signal with (1) a manual analysis and (2) using a standardized fully automated method. Results Fifty-two patients (median age 6 months) were included in the analysis. Eighteen patients had a very low ventilatory drive (i.e., peak Edi < 2 µV on average), which prevented the calculation of patient–ventilator asynchrony. Children spent 27% (interquartile 22–39%) of the time in conflict with the ventilator. Cycling-off errors and trigger delays contributed to most of this asynchronous time. The automatic algorithm provided a NeuroSync index of 45%, confirming the high prevalence of asynchrony. No association between the severity of asynchrony and ventilator-free days at day 28 or any other clinical secondary outcomes was observed, but the proportion of children with good synchrony was very low. Conclusion Patient–ventilator interaction is poor in children supported by conventional ventilation, with a high frequency of depressed ventilatory drive and a large proportion of time spent in asynchrony. The clinical benefit of strategies to improve patient–ventilator interactions should be evaluated in pediatric critical care.
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Affiliation(s)
- Guillaume Mortamet
- Pediatric Intensive Care Unit, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, QC, Canada.,INSERM U 955, Equipe 13, Créteil, France.,CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada
| | - Alexandrine Larouche
- Pediatric Intensive Care Unit, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, QC, Canada.,CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada
| | - Laurence Ducharme-Crevier
- Pediatric Intensive Care Unit, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, QC, Canada.,CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada
| | - Olivier Fléchelles
- Pediatric Intensive Care Unit, CHU Fort-de-France, Fort-de-France, France
| | - Gabrielle Constantin
- Pediatric Intensive Care Unit, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, QC, Canada.,CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada
| | - Sandrine Essouri
- CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada.,Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada
| | | | - Jennifer Beck
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada.,Institute for Biomedical Engineering and Science Technology (iBEST), Ryerson University and St-Michael's Hospital, Toronto, Canada
| | - Christer Sinderby
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Institute for Biomedical Engineering and Science Technology (iBEST), Ryerson University and St-Michael's Hospital, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Philippe Jouvet
- Pediatric Intensive Care Unit, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, QC, Canada.,CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada
| | - Guillaume Emeriaud
- Pediatric Intensive Care Unit, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, QC, Canada. .,CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada.
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Bedside Ultrasound for the Diagnosis of Abnormal Diaphragmatic Motion in Children After Heart Surgery. Pediatr Crit Care Med 2017; 18:159-164. [PMID: 27801709 DOI: 10.1097/pcc.0000000000001015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the utility of bedside ultrasound combining B- and M-mode in the diagnosis of abnormal diaphragmatic motion in children after heart surgery. DESIGN Prospective post hoc blinded comparison of ultrasound performed by two different intensivists and fluoroscopy results with electromyography. SETTING Tertiary university hospital. SUBJECTS Children with suspected abnormal diaphragmatic motion after heart surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Abnormal diaphragmatic motion was suspected in 26 children. Electromyography confirmed the diagnosis in 20 of 24 children (83.3%). The overall occurrence rate of abnormal diaphragmatic motion during the study period was 7.5%. Median patient age was 5 months (range, 16 d to 14 yr). Sensitivity and specificity of chest ultrasound performed at the bedside by the two intensivists (91% and 92% and 92% and 95%, respectively) were higher than those obtained by fluoroscopy (87% and 83%). Interobserver agreement (k) between both intensivists was 0.957 (95% CI, 0.87-100). CONCLUSIONS Chest ultrasound performed by intensivists is a valid tool for the diagnosis of diaphragmatic paralysis, presenting greater sensitivity and specificity than fluoroscopy. Chest ultrasound should be routinely used after pediatric heart surgery given its reliability, reproducibility, availability, and safety.
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Rabec C, Emeriaud G, Amadeo A, Fauroux B, Georges M. New modes in non-invasive ventilation. Paediatr Respir Rev 2016; 18:73-84. [PMID: 26688194 DOI: 10.1016/j.prrv.2015.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 10/19/2015] [Indexed: 02/07/2023]
Abstract
Non-invasive ventilation is useful to treat some forms of respiratory failure. Hence, the number of patients receiving this treatment is steadily increasing. Considerable conceptual and technical progress has been made in the last years by manufacturers concerning this technique. This includes new features committed to improve its effectiveness as well as patient-ventilator interactions. The goal of this review is to deal with latest advances in ventilatory modes and features available for non-invasive ventilation. We present a comprehensive analysis of new modes of ventilator assistance committed to treat respiratory failure (hybrid modes) and central and complex sleep apnea (adaptive servo ventilation), and of new modes of triggering and cycling (neurally adjusted ventilatory assist). Technical aspects, modes of operation and settings of these new features as well as an exhaustive review of published data, their benefits and limits, and the potential place of these devices in clinical practice, are discussed.
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Affiliation(s)
- Claudio Rabec
- Pulmonary Departement and Respiratory Critical Care Unit, University Hospital Dijon, France; Inserm U 866, University of Burgundy, School of Medicine, Dijon, France.
| | - Guillaume Emeriaud
- Pediatric Intensive Care Unit, Saint Justine Hospital, Université de Montréal, Montreal, Canada
| | - Alessandro Amadeo
- AP-HP, Hôpital Necker, Pediatric Noninvasive Ventilation and Sleep Unit, Paris, France; Paris Descartes University, France; Inserm U 955, Team 13, Créteil, France
| | - Brigitte Fauroux
- AP-HP, Hôpital Necker, Pediatric Noninvasive Ventilation and Sleep Unit, Paris, France; Paris Descartes University, France; Inserm U 955, Team 13, Créteil, France
| | - Marjolaine Georges
- Pulmonary Departement and Respiratory Critical Care Unit, University Hospital Dijon, France; Inserm U 866, University of Burgundy, School of Medicine, Dijon, France
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Emeriaud G, Larouche A, Ducharme-Crevier L, Massicotte E, Fléchelles O, Pellerin-Leblanc AA, Morneau S, Beck J, Jouvet P. Evolution of inspiratory diaphragm activity in children over the course of the PICU stay. Intensive Care Med 2014; 40:1718-26. [PMID: 25118865 DOI: 10.1007/s00134-014-3431-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 07/30/2014] [Indexed: 01/06/2023]
Abstract
PURPOSE Diaphragm function should be monitored in critically ill patients, as full ventilatory support rapidly induces diaphragm atrophy. Monitoring the electrical activity of the diaphragm (EAdi) may help assess the level of diaphragm activity, but such monitoring results are difficult to interpret because reference values are lacking. The aim of this study was to describe EAdi values in critically ill children during a stay in the pediatric intensive care unit (PICU), from the acute to recovery phases, and to assess the impact of ventilatory support on EAdi. METHODS This was a prospective longitudinal observational study of children requiring mechanical ventilation for ≥24 h. EAdi was recorded using a validated method in the acute phase, before extubation, after extubation, and before PICU discharge. RESULTS Fifty-five critically ill children were enrolled in the study. Median maximum inspiratory EAdi (EAdimax) during mechanical ventilation was 3.6 [interquartile range (IQR) 1.2-7.6] μV in the acute phase and 4.8 (IQR 2.0-10.7) μV in the pre-extubation phase. Periods of diaphragm inactivity (with no detectable inspiratory EAdi) were frequent during conventional ventilation, even with a low level of support. EAdimax in spontaneous ventilation was 15.4 (IQR 7.4-20.7) μV shortly after extubation and 12.6 (IQR 8.1-21.3) μV before PICU discharge. The difference in EAdimax between mechanical ventilation and post-extubation periods was significant (p < 0.001). Patients intubated mainly because of a lung pathology exhibited higher EAdi (p < 0.01), with a similar temporal increase. CONCLUSIONS This is the first systematic description of EAdi evolution in children during their stay in the PICU. In our patient cohort, diaphragm activity was frequently low in conventional ventilation, suggesting that overassistance or oversedation is common in clinical practice. EAdi monitoring appears to be a helpful tool to detect such situations.
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Affiliation(s)
- Guillaume Emeriaud
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada,
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Nisula S, Kaukonen KM, Vaara ST, Korhonen AM, Poukkanen M, Karlsson S, Haapio M, Inkinen O, Parviainen I, Suojaranta-Ylinen R, Laurila JJ, Tenhunen J, Reinikainen M, Ala-Kokko T, Ruokonen E, Kuitunen A, Pettilä V. Incidence, risk factors and 90-day mortality of patients with acute kidney injury in Finnish intensive care units: the FINNAKI study. Intensive Care Med 2013; 39:420-8. [DOI: 10.1007/s00134-012-2796-5] [Citation(s) in RCA: 241] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Accepted: 10/23/2012] [Indexed: 02/07/2023]
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