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Demoule A, Decavele M, Antonelli M, Camporota L, Abroug F, Adler D, Azoulay E, Basoglu M, Campbell M, Grasselli G, Herridge M, Johnson MJ, Naccache L, Navalesi P, Pelosi P, Schwartzstein R, Williams C, Windisch W, Heunks L, Similowski T. Dyspnoea in acutely ill mechanically ventilated adult patients: an ERS/ESICM statement. Eur Respir J 2024; 63:2300347. [PMID: 38387998 DOI: 10.1183/13993003.00347-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 09/16/2023] [Indexed: 02/24/2024]
Abstract
This statement outlines a review of the literature and current practice concerning the prevalence, clinical significance, diagnosis and management of dyspnoea in critically ill, mechanically ventilated adult patients. It covers the definition, pathophysiology, epidemiology, short- and middle-term impact, detection and quantification, and prevention and treatment of dyspnoea. It represents a collaboration of the European Respiratory Society and the European Society of Intensive Care Medicine. Dyspnoea ranks among the most distressing experiences that human beings can endure. Approximately 40% of patients undergoing invasive mechanical ventilation in the intensive care unit (ICU) report dyspnoea, with an average intensity of 45 mm on a visual analogue scale from 0 to 100 mm. Although it shares many similarities with pain, dyspnoea can be far worse than pain in that it summons a primal fear response. As such, it merits universal and specific consideration. Dyspnoea must be identified, prevented and relieved in every patient. In the ICU, mechanically ventilated patients are at high risk of experiencing breathing difficulties because of their physiological status and, in some instances, because of mechanical ventilation itself. At the same time, mechanically ventilated patients have barriers to signalling their distress. Addressing this major clinical challenge mandates teaching and training, and involves ICU caregivers and patients. This is even more important because, as opposed to pain which has become a universal healthcare concern, very little attention has been paid to the identification and management of respiratory suffering in mechanically ventilated ICU patients.
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Affiliation(s)
- Alexandre Demoule
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation, Département R3S, F-75013 Paris, France
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, France
| | - Maxens Decavele
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation, Département R3S, F-75013 Paris, France
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, France
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luigi Camporota
- Department of Adult Critical Care, Health Centre for Human and Applied Physiological Sciences, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Fekri Abroug
- ICU and Research Lab (LR12SP15), Fattouma Bourguiba Teaching Hospital, Monastir, Tunisia
| | - Dan Adler
- Division of Pulmonary Diseases, Hôpital de la Tour, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Elie Azoulay
- Medical Intensive Care Unit, APHP Hôpital Saint-Louis, Paris, France
| | - Metin Basoglu
- Istanbul Center for Behaviorial Sciences (DABATEM), Istanbul, Turkey
| | | | - Giacomo Grasselli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Anesthesia, Critical Care and Emergency, Milan, Italy
- University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy
| | - Margaret Herridge
- Toronto General Research Institute, University Health Network, Toronto, ON, Canada
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Lionel Naccache
- Département de Neurophysiologie, Sorbonne Université, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
- Institut du Cerveau et de la Moelle Épinière, ICM, PICNIC Lab, Paris, France
| | - Paolo Navalesi
- Department of Medicine, University of Padua, Padua, Italy
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Richard Schwartzstein
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Wolfram Windisch
- Department of Pneumology, Cologne Merheim Hospital, Kliniken der Stadt Köln, Witten/Herdecke University, Cologne, Germany
| | - Leo Heunks
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
- L. Heunks and T. Similowski contributed equally to the manuscript
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département R3S, F-75013 Paris, France
- L. Heunks and T. Similowski contributed equally to the manuscript
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Demoule A, Decavele M, Antonelli M, Camporota L, Abroug F, Adler D, Azoulay E, Basoglu M, Campbell M, Grasselli G, Herridge M, Johnson MJ, Naccache L, Navalesi P, Pelosi P, Schwartzstein R, Williams C, Windisch W, Heunks L, Similowski T. Dyspnoea in acutely ill mechanically ventilated adult patients: an ERS/ESICM statement. Intensive Care Med 2024; 50:159-180. [PMID: 38388984 DOI: 10.1007/s00134-023-07246-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 09/16/2023] [Indexed: 02/24/2024]
Abstract
This statement outlines a review of the literature and current practice concerning the prevalence, clinical significance, diagnosis and management of dyspnoea in critically ill, mechanically ventilated adult patients. It covers the definition, pathophysiology, epidemiology, short- and middle-term impact, detection and quantification, and prevention and treatment of dyspnoea. It represents a collaboration of the European Respiratory Society (ERS) and the European Society of Intensive Care Medicine (ESICM). Dyspnoea ranks among the most distressing experiences that human beings can endure. Approximately 40% of patients undergoing invasive mechanical ventilation in the intensive care unit (ICU) report dyspnoea, with an average intensity of 45 mm on a visual analogue scale from 0 to 100 mm. Although it shares many similarities with pain, dyspnoea can be far worse than pain in that it summons a primal fear response. As such, it merits universal and specific consideration. Dyspnoea must be identified, prevented and relieved in every patient. In the ICU, mechanically ventilated patients are at high risk of experiencing breathing difficulties because of their physiological status and, in some instances, because of mechanical ventilation itself. At the same time, mechanically ventilated patients have barriers to signalling their distress. Addressing this major clinical challenge mandates teaching and training, and involves ICU caregivers and patients. This is even more important because, as opposed to pain which has become a universal healthcare concern, very little attention has been paid to the identification and management of respiratory suffering in mechanically ventilated ICU patients.
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Affiliation(s)
- Alexandre Demoule
- Service de Médecine Intensive-Réanimation, Département R3S, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France.
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France.
| | - Maxens Decavele
- Service de Médecine Intensive-Réanimation, Département R3S, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luigi Camporota
- Department of Adult Critical Care, Health Centre for Human and Applied Physiological Sciences, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Fekri Abroug
- ICU and Research Lab (LR12SP15), Fattouma Bourguiba Teaching Hospital, Monastir, Tunisia
| | - Dan Adler
- Division of Pulmonary Diseases, Hôpital de la Tour, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Elie Azoulay
- Medical Intensive Care Unit, APHP Hôpital Saint-Louis, Paris, France
| | - Metin Basoglu
- Istanbul Center for Behavioral Sciences (DABATEM), Istanbul, Turkey
| | | | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Margaret Herridge
- Toronto General Research Institute, University Health Network, Toronto, ON, Canada
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Lionel Naccache
- Département de Neurophysiologie, Sorbonne Université, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Paris, France
- Institut du Cerveau et de la Moelle Épinière, ICM, PICNIC Lab, Paris, France
| | - Paolo Navalesi
- Department of Medicine, University of Padua, Padua, Italy
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Richard Schwartzstein
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Wolfram Windisch
- Department of Pneumology, Cologne Merheim Hospital, Kliniken der Stadt Köln, Witten/Herdecke University, Cologne, Germany
| | - Leo Heunks
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France
- Département R3S, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France
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Abstract
PURPOSE OF REVIEW The last 25 years have seen considerable development in modes of closed-loop ventilation and there are now several of them commercially available. They not only offer potential benefits for the individual patient, but may also improve the organization within the intensive care unit (ICU). Clinicians are showing both greater interest and willingness to address the issues of a caregiver shortage and overload of bedside work in the ICU. This article reviews the clinical benefits of using closed-loop ventilation modes, with a focus on control of oxygenation, lung protection, and weaning. RECENT FINDINGS Closed-loop ventilation modes are able to maintain important physiological variables, such as oxygen saturation measured by pulse oximetry, tidal volume (VT), driving pressure (ΔP), and mechanical power (MP), within target ranges aimed at ensuring continuous lung protection. In addition, these modes adapt the ventilator support to the patient's needs, promoting diaphragm activity and preventing over-assistance. Some studies have shown the potential of these modes to reduce the duration of both weaning and mechanical ventilation. SUMMARY Recent studies have primarily demonstrated the safety, efficacy, and feasibility of using closed-loop ventilation modes in the ICU and postsurgery patients. Large, multicenter randomized controlled trials are needed to assess their impact on important short- and long-term clinical outcomes, the organization of the ICU, and cost-effectiveness.
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Affiliation(s)
- Jean-Michel Arnal
- Service de réanimation polyvalente, Hôpital Sainte Musse, Toulon, France
- Department of Research and New Technologies, Hamilton Medical, Bonaduz, Switzerland
| | - Shinshu Katayama
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Christopher Howard
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, Texas, USA
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Pulmonary volume-feedback and ventilatory pattern after bilateral lung transplantation using neurally adjusted ventilatory assist ventilation. Br J Anaesth 2021; 127:143-152. [PMID: 33892948 DOI: 10.1016/j.bja.2021.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 02/23/2021] [Accepted: 03/01/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Bilateral lung transplantation results in pulmonary vagal denervation, which potentially alters respiratory drive, volume-feedback, and ventilatory pattern. We hypothesised that Neurally Adjusted Ventilatory Assist (NAVA) ventilation, which is driven by diaphragm electrical activity (EAdi), would reveal whether vagally mediated pulmonary-volume feedback is preserved in the early phases after bilateral lung transplantation. METHODS We prospectively studied bilateral lung transplant recipients within 48 h of surgery. Subjects were ventilated with NAVA and randomised to receive 3 ventilatory modes (baseline NAVA, 50%, and 150% of baseline NAVA values) and 2 PEEP levels (6 and 12 cm H2O). We recorded airway pressure, flow, and EAdi. RESULTS We studied 30 subjects (37% female; age: 37 (27-56) yr), of whom 19 (63%) had stable EAdi. The baseline NAVA level was 0.6 (0.2-1.0) cm H2O μV-1. Tripling NAVA level increased the ventilatory peak pressure over PEEP by 6.3 (1.8), 7.6 (2.4), and 8.7 (3.2) cm H2O, at 50%, 100%, and 150% of baseline NAVA level, respectively (P<0.001). EAdi peak decreased by 10.1 (9.0), 9.5 (9.4) and 8.8 μV (8.7) (P<0.001), accompanied by small increases in tidal volume, 8.3 (3.0), 8.7 (3.6), and 8.9 (3.3) ml kg-1 donor's predicted body weight at 50%, 100%, and 150% of baseline NAVA levels, respectively (P<0.001). Doubling PEEP did not affect tidal volume. CONCLUSIONS NAVA ventilation was feasible in the majority of patients during the early postoperative period after bilateral lung transplantation. Despite surgical vagotomy distal to the bronchial anastomoses, bilateral lung transplant recipients maintained an unmodified respiratory pattern in response to variations in ventilatory assistance and PEEP. CLINICAL TRIAL REGISTRATION NCT03367221.
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Schönhofer B, Geiseler J, Dellweg D, Fuchs H, Moerer O, Weber-Carstens S, Westhoff M, Windisch W. Prolonged Weaning: S2k Guideline Published by the German Respiratory Society. Respiration 2020; 99:1-102. [PMID: 33302267 DOI: 10.1159/000510085] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 01/28/2023] Open
Abstract
Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by respiratory muscle insufficiency and/or lung parenchymal disease; that is, when other treatments such as medication, oxygen administration, secretion management, continuous positive airway pressure (CPAP), or nasal high-flow therapy have failed. MV is required for maintaining gas exchange and allows more time to curatively treat the underlying cause of respiratory failure. In the majority of ventilated patients, liberation or "weaning" from MV is routine, without the occurrence of any major problems. However, approximately 20% of patients require ongoing MV, despite amelioration of the conditions that precipitated the need for it in the first place. Approximately 40-50% of the time spent on MV is required to liberate the patient from the ventilator, a process called "weaning". In addition to acute respiratory failure, numerous factors can influence the duration and success rate of the weaning process; these include age, comorbidities, and conditions and complications acquired during the ICU stay. According to international consensus, "prolonged weaning" is defined as the weaning process in patients who have failed at least 3 weaning attempts, or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Given that prolonged weaning is a complex process, an interdisciplinary approach is essential for it to be successful. In specialised weaning centres, approximately 50% of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, the heterogeneity of patients undergoing prolonged weaning precludes the direct comparison of individual centres. Patients with persistent weaning failure either die during the weaning process, or are discharged back to their home or to a long-term care facility with ongoing MV. Urged by the growing importance of prolonged weaning, this Sk2 Guideline was first published in 2014 as an initiative of the German Respiratory Society (DGP), in conjunction with other scientific societies involved in prolonged weaning. The emergence of new research, clinical study findings and registry data, as well as the accumulation of experience in daily practice, have made the revision of this guideline necessary. The following topics are dealt with in the present guideline: Definitions, epidemiology, weaning categories, underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV, and recommendations for end-of-life decisions. Special emphasis was placed on the following themes: (1) A new classification of patient sub-groups in prolonged weaning. (2) Important aspects of pulmonary rehabilitation and neurorehabilitation in prolonged weaning. (3) Infrastructure and process organisation in the care of patients in prolonged weaning based on a continuous treatment concept. (4) Changes in therapeutic goals and communication with relatives. Aspects of paediatric weaning are addressed separately within individual chapters. The main aim of the revised guideline was to summarize both current evidence and expert-based knowledge on the topic of "prolonged weaning", and to use this information as a foundation for formulating recommendations related to "prolonged weaning", not only in acute medicine but also in the field of chronic intensive care medicine. The following professionals served as important addressees for this guideline: intensivists, pulmonary medicine specialists, anaesthesiologists, internists, cardiologists, surgeons, neurologists, paediatricians, geriatricians, palliative care clinicians, rehabilitation physicians, intensive/chronic care nurses, physiotherapists, respiratory therapists, speech therapists, medical service of health insurance, and associated ventilator manufacturers.
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Affiliation(s)
- Bernd Schönhofer
- Klinikum Agnes Karll Krankenhaus, Klinikum Region Hannover, Laatzen, Germany,
| | - Jens Geiseler
- Klinikum Vest, Medizinische Klinik IV: Pneumologie, Beatmungs- und Schlafmedizin, Marl, Germany
| | - Dominic Dellweg
- Fachkrankenhaus Kloster Grafschaft GmbH, Abteilung Pneumologie II, Schmallenberg, Germany
| | - Hans Fuchs
- Universitätsklinikum Freiburg, Zentrum für Kinder- und Jugendmedizin, Neonatologie und Pädiatrische Intensivmedizin, Freiburg, Germany
| | - Onnen Moerer
- Universitätsmedizin Göttingen, Klinik für Anästhesiologie, Göttingen, Germany
| | - Steffen Weber-Carstens
- Charité, Universitätsmedizin Berlin, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Virchow-Klinikum und Campus Mitte, Berlin, Germany
| | - Michael Westhoff
- Lungenklinik Hemer, Hemer, Germany
- Universität Witten/Herdecke, Herdecke, Germany
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Universität Witten/Herdecke, Herdecke, Germany
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Effect of Neurally Adjusted Ventilatory Assist on Patient-Ventilator Interaction in Mechanically Ventilated Adults: A Systematic Review and Meta-Analysis. Crit Care Med 2020; 47:e602-e609. [PMID: 30882481 DOI: 10.1097/ccm.0000000000003719] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Patient-ventilator asynchrony is common among critically ill patients undergoing mechanical ventilation and has been associated with adverse outcomes. Neurally adjusted ventilatory assist is a ventilatory mode that may lead to improved patient-ventilator synchrony. We conducted a systematic review to determine the impact of neurally adjusted ventilatory assist on patient-ventilator asynchrony, other physiologic variables, and clinical outcomes in adult patients undergoing invasive mechanical ventilation in comparison with conventional pneumatically triggered ventilatory modes. DATA SOURCES We searched Medline, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central, CINAHL, Scopus, Web of Science, conference abstracts, and ClinicalTrials.gov until July 2018. STUDY SELECTION Two authors independently screened titles and abstracts for randomized and nonrandomized controlled trials (including crossover design) comparing the occurrence of patient-ventilator asynchrony between neurally adjusted ventilatory assist and pressure support ventilation during mechanical ventilation in critically ill adults. The asynchrony index and severe asynchrony (i.e., asynchrony index > 10%) were the primary outcomes. DATA EXTRACTION Two authors independently extracted study characteristics and outcomes and assessed risk of bias of included studies. DATA SYNTHESIS Of 11,139 unique citations, 26 studies (522 patients) met the inclusion criteria. Sixteen trials were included in the meta-analysis using random effects models through the generic inverse variance method. In several different clinical scenarios, the use of neurally adjusted ventilatory assist was associated with significantly reduced asynchrony index (mean difference, -8.12; 95% CI, -11.61 to -4.63; very low quality of evidence) and severe asynchrony (odds ratio, 0.42; 95% CI, 0.23-0.76; moderate quality of evidence) as compared with pressure support ventilation. Furthermore, other measurements of asynchrony were consistently improved during neurally adjusted ventilatory assist. CONCLUSIONS Neurally adjusted ventilatory assist improves patient-ventilator synchrony; however, its effects on clinical outcomes remain uncertain. Randomized controlled trials are needed to determine whether the physiologic efficiency of neurally adjusted ventilatory assist affects patient-important outcomes in critically ill adults.
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Tagliabue G, Ji M, Suneby Jagers JV, Zuege DJ, Kortbeek JB, Easton PA. Distinct neural-mechanical efficiency of costal and crural diaphragm during hypercapnia. Respir Physiol Neurobiol 2019; 268:103247. [PMID: 31247325 DOI: 10.1016/j.resp.2019.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 05/30/2019] [Accepted: 06/23/2019] [Indexed: 11/30/2022]
Abstract
Classic physiology suggests that the two distinct diaphragm segments, costal and crural, are functionally different. It is not known if the two diaphragm muscles share a common neural mechanical activation. We hypothesized that costal and crural diaphragm are recruited differently during hypercapnic stimulated ventilation, and the EMG recordings of the esophageal crural diaphragm segment does not translate to the same level of mechanical shortening for costal and crural segments In 30 spontaneously breathing canines, without confounding anesthetic, we measured directly electrical activity and corresponding mechanical shortening of both the costal and crural diaphragm, at room air and during increasing hypercapnia. During hypercapnic ventilation, the costal diaphragm showed a predominant recruitment over the crural diaphragm. The distinct mechanical contribution of the costal segment was not due to a different level of neural activation between the two muscles as measured by segmental EMG activity. Thus, the two diaphragm segments exhibited a significantly different neural-mechanical relationship.
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Affiliation(s)
- Giovanni Tagliabue
- Department of Critical Care Medicine, Cumming School of Medicine, Calgary, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - Michael Ji
- Department of Critical Care Medicine, Cumming School of Medicine, Calgary, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - Jenny V Suneby Jagers
- Department of Critical Care Medicine, Cumming School of Medicine, Calgary, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - Dan J Zuege
- Department of Critical Care Medicine, Cumming School of Medicine, Calgary, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - John B Kortbeek
- Department of Critical Care Medicine, Cumming School of Medicine, Calgary, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - Paul A Easton
- Department of Critical Care Medicine, Cumming School of Medicine, Calgary, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 4N1, Canada.
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Bruni A, Garofalo E, Pelaia C, Messina A, Cammarota G, Murabito P, Corrado S, Vetrugno L, Longhini F, Navalesi P. Patient-ventilator asynchrony in adult critically ill patients. Minerva Anestesiol 2019; 85:676-688. [PMID: 30762325 DOI: 10.23736/s0375-9393.19.13436-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Patient-ventilator asynchrony is considered a major clinical problem for mechanically ventilated patients. It occurs during partial ventilatory support, when the respiratory muscles and the ventilator interact to contribute generating the volume output. In this review article, we consider all studies published on patient-ventilator asynchrony in the last 25 years. EVIDENCE ACQUISITION We selected 62 studies. The different forms of asynchrony are first defined and classified. We also describe the methods used for detecting and quantifying asynchronies. We then outline the outcome variables considered for evaluating the clinical consequences of asynchronies. The methodology for detection and quantification of patient-ventilator asynchrony are quite heterogeneous. In particular, the Asynchrony Index is calculated differently among studies. EVIDENCE SYNTHESIS Sixteen studies established some relationship between asynchronies and one or more clinical outcomes, such as duration of mechanical ventilation (seven studies), mortality (five studies), length of intensive care and hospital stay (four studies), patient comfort (four studies), quality of sleep (three studies), and rate of tracheotomy (three studies). In patients with severe patient-ventilator asynchrony, four of seven studies (57%) report prolonged duration of mechanical ventilation, one of five (20%) increased mortality, one of four (25%) longer intensive care and hospital lengths of stay, four of four (100%) worsened comfort, three of four (75%) deteriorated quality of sleep, and one of three (33%) increased rate of tracheotomy. CONCLUSIONS Given the varying outcomes considered and the erratic results, it remains unclear whether asynchronies really affects patient outcome, and the relationship between asynchronies and outcome is causative or associative.
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Affiliation(s)
- Andrea Bruni
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Eugenio Garofalo
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Corrado Pelaia
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | | | - Gianmaria Cammarota
- Unit of Anesthesia and Intensive Care, "Maggiore della Carità" Hospital, Novara, Italy
| | - Paolo Murabito
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", "G. Rodolico" University Policlinic, University of Catania, Catania, Italy
| | - Silvia Corrado
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Luigi Vetrugno
- Department of Anesthesia and Intensive Care, University of Udine, Udine, Italy
| | - Federico Longhini
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy -
| | - Paolo Navalesi
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
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Lamouret O, Crognier L, Vardon Bounes F, Conil JM, Dilasser C, Raimondi T, Ruiz S, Rouget A, Delmas C, Seguin T, Minville V, Georges B. Neurally adjusted ventilatory assist (NAVA) versus pressure support ventilation: patient-ventilator interaction during invasive ventilation delivered by tracheostomy. Crit Care 2019; 23:2. [PMID: 30616669 PMCID: PMC6323755 DOI: 10.1186/s13054-018-2288-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 12/04/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prolonged weaning is a major issue in intensive care patients and tracheostomy is one of the last resort options. Optimized patient-ventilator interaction is essential to weaning. The purpose of this study was to compare patient-ventilator synchrony between pressure support ventilation (PSV) and neurally adjusted ventilatory assist (NAVA) in a selected population of tracheostomised patients. METHODS We performed a prospective, sequential, non-randomized and single-centre study. Two recording periods of 60 min of airway pressure, flow, and electrical activity of the diaphragm during PSV and NAVA were recorded in a random assignment and eight periods of 1 min were analysed for each mode. We searched for macro-asynchronies (ineffective, double, and auto-triggering) and micro-asynchronies (inspiratory trigger delay, premature, and late cycling). The number and type of asynchrony events per minute and asynchrony index (AI) were determined. The two respiratory phases were compared using the non-parametric Wilcoxon test after testing the equality of the two variances (F-Test). RESULTS Among the 61 patients analysed, the total AI was lower in NAVA than in PSV mode: 2.1% vs 14% (p < 0.0001). This was mainly due to a decrease in the micro-asynchronies index: 0.35% vs 9.8% (p < 0.0001). The occurrence of macro-asynchronies was similar in both ventilator modes except for double triggering, which increased in NAVA. The tidal volume (ml/kg) was lower in NAVA than in PSV (5.8 vs 6.2, p < 0.001), and the respiratory rate was higher in NAVA than in PSV (28 vs 26, p < 0.05). CONCLUSION NAVA appears to be a promising ventilator mode in tracheotomised patients, especially for those requiring prolonged weaning due to the decrease in asynchronies.
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Affiliation(s)
- Olivier Lamouret
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France. .,Department of Anaesthesiology and Critical Care Unit, University Hospital of Toulouse, 31059, Toulouse Cedex 9, France.
| | - Laure Crognier
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Fanny Vardon Bounes
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Jean-Marie Conil
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Caroline Dilasser
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Thibaut Raimondi
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Stephanie Ruiz
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Antoine Rouget
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Clément Delmas
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Thierry Seguin
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Vincent Minville
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Bernard Georges
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
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Ambrosino N, Vitacca M. The patient needing prolonged mechanical ventilation: a narrative review. Multidiscip Respir Med 2018; 13:6. [PMID: 29507719 PMCID: PMC5831532 DOI: 10.1186/s40248-018-0118-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 02/07/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Progress in management has improved hospital mortality of patients admitted to the intensive care units, but also the prevalence of those patients needing weaning from prolonged mechanical ventilation, and of ventilator assisted individuals. The result is a number of difficult clinical and organizational problems for patients, caregivers and health services, as well as high human and financial resources consumption, despite poor long-term outcomes. An effort should be made to improve the management of these patients. This narrative review summarizes the main concepts in this field. MAIN BODY There is great variability in terminology and definitions of prolonged mechanical ventilation.There have been several recent developments in the field of prolonged weaning: ventilatory strategies, use of protocols, early mobilisation and physiotherapy, specialised weaning units.There are few published data on discharge home rates, need of home mechanical ventilation, or long-term survival of these patients.Whether artificial nutritional support improves the outcome for these chronic critically ill patients, is unclear and controversial how these data are reported on the optimal time of initiation of parenteral vs enteral nutrition.There is no consensus on time of tracheostomy or decannulation. Despite several individualized, non-comparative and non-validated decannulation protocols exist, universally accepted protocols are lacking as well as randomised controlled trials on this critical issue. End of life decisions should result from appropriate communication among professionals, patients and surrogates and national legislations should give clear indications. CONCLUSION Present medical training of clinicians and locations like traditional intensive care units do not appear enough to face the dramatic problems posed by these patients. The solutions cannot be reserved to professionals but must involve also families and all other stakeholders. Large multicentric, multinational studies on several aspects of management are needed.
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Affiliation(s)
- Nicolino Ambrosino
- Istituti Clinici Scientifici Maugeri, IRCCS, Istituto Scientifico di Montescano, 27040 Montescano, PV Italy
| | - Michele Vitacca
- Istituti Clinici Scientifici Maugeri, IRCCS, Respiratory Unit, Istituto Scientifico di Lumezzane, Lumezzane, BS Italy
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Ferreira JC, Diniz-Silva F, Moriya HT, Alencar AM, Amato MBP, Carvalho CRR. Neurally Adjusted Ventilatory Assist (NAVA) or Pressure Support Ventilation (PSV) during spontaneous breathing trials in critically ill patients: a crossover trial. BMC Pulm Med 2017; 17:139. [PMID: 29115949 PMCID: PMC5678780 DOI: 10.1186/s12890-017-0484-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 10/31/2017] [Indexed: 12/12/2022] Open
Abstract
Background Neurally Adjusted Ventilatory Assist (NAVA) is a proportional ventilatory mode that uses the electrical activity of the diaphragm (EAdi) to offer ventilatory assistance in proportion to patient effort. NAVA has been increasingly used for critically ill patients, but it has not been evaluated during spontaneous breathing trials (SBT). We designed a pilot trial to assess the feasibility of using NAVA during SBTs, and to compare the breathing pattern and patient-ventilator asynchrony of NAVA with Pressure Support (PSV) during SBTs. Methods We conducted a crossover trial in the ICU of a university hospital in Brazil and included mechanically ventilated patients considered ready to undergo an SBT on the day of the study. Patients underwent two SBTs in randomized order: 30 min in PSV of 5 cmH2O or NAVA titrated to generate equivalent peak airway pressure (Paw), with a positive end-expiratory pressure of 5 cmH2O. The ICU team, blinded to ventilatory mode, evaluated whether patients passed each SBT. We captured flow, Paw and electrical activity of the diaphragm (EAdi) from the ventilator and used it to calculate respiratory rate (RR), tidal volume (VT), and EAdi. Detection of asynchrony events used waveform analysis and we calculated the asynchrony index as the number of asynchrony events divided by the number of neural cycles. Results We included 20 patients in the study. All patients passed the SBT in PSV, and three failed the SBT in NAVA. Five patients were reintubated and the extubation failure rate was 25% (95% CI 9–49%). Respiratory parameters were similar in the two modes: VT = 6.1 (5.5–6.5) mL/Kg in NAVA vs. 5.5 (4.8–6.1) mL/Kg in PSV (p = 0.076) and RR = 27 (17–30) rpm in NAVA vs. 26 (20–30) rpm in PSV, p = 0.55. NAVA reduced AI, with a median of 11.5% (4.2–19.7) compared to 24.3% (6.3–34.3) in PSV (p = 0.033). Conclusions NAVA reduces patient-ventilator asynchrony index and generates a respiratory pattern similar to PSV during SBTs. Patients considered ready for mechanical ventilation liberation may be submitted to an SBT in NAVA using the same objective criteria used for SBTs in PSV. Trial registration ClinicalTrials.gov (NCT01337271), registered April 12, 2011. Electronic supplementary material The online version of this article (10.1186/s12890-017-0484-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Juliana C Ferreira
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil.
| | - Fabia Diniz-Silva
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Henrique T Moriya
- Biomedical Engineering Laboratory, Escola Politécnica da Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Adriano M Alencar
- Instituto de Física, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Marcelo B P Amato
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Carlos R R Carvalho
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil
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Abstract
Controlled Mechanical Ventilation may be essential in the setting of severe respiratory failure but consequences to the patient including increased use of sedation and neuromuscular blockade may contribute to delirium, atelectasis, and diaphragm dysfunction. Assisted ventilation allows spontaneous breathing activity to restore physiological displacement of the diaphragm and recruit better perfused lung regions. Pressure Support Ventilation is the most frequently used mode of assisted mechanical ventilation. However, this mode continues to provide a monotonous pattern of support for respiration which is normally a dynamic process. Noisy Pressure Support Ventilation where tidal volume is varied randomly by the ventilator may improve ventilation and perfusion matching but the degree of support is still determined by the ventilator. Two more recent modes of ventilation, Proportional Assist Ventilation and Neurally Adjusted Ventilatory Assist (NAVA), allow patient determination of the pattern and depth of ventilation. Proposed advantages of Proportional Assist Ventilation and NAVA include decrease in patient ventilator asynchrony and improved adaptation of ventilator support to changing patient demand. Work of breathing can be normalized with these modes as well. To date, however, a clear pattern of clinical benefit has not been demonstrated. Existing challenges for both of the newer assist modes include monitoring patients with dynamic hyperinflation (auto-positive end expiratory pressure), obstructive lung disease, and air leaks in the ventilator system. NAVA is dependent on consistent transduction of diaphragm activity by an electrode system placed in the esophagus. Longevity of effective support with this technique is unclear.
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13
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Bruells CS, Breuer T, Maes K, Bergs I, Bleilevens C, Marx G, Weis J, Gayan-Ramirez G, Rossaint R. Influence of weaning methods on the diaphragm after mechanical ventilation in a rat model. BMC Pulm Med 2016; 16:127. [PMID: 27558126 PMCID: PMC4997706 DOI: 10.1186/s12890-016-0285-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 08/11/2016] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Mechanical ventilation (MV) is associated with diaphragm weakness, a phenomenon termed ventilator-induced diaphragmatic dysfunction. Weaning should balance diaphragmatic loading as well as prevention of overload after MV. The weaning methods pressure support ventilation (PSV) and spontaneous breathing trials (SBT) lead to gradual or intermittent reloading of a weak diaphragm, respectively. This study investigated which weaning method allows more efficient restoration of diaphragm homeostasis. METHODS Rats (n = 8 per group) received 12 h of MV followed by either 12 h of pressure support ventilation (PSV) or intermittent spontaneous breathing trials (SBT) and were compared to rats euthanized after 12 h MV (CMV) and to acutely euthanized rats (CON). Force generation, activity of calpain-1 and caspase-3, oxidative stress, and markers of protein synthesis (phosphorylated AKT to total AKT) were measured in the diaphragm. RESULTS Reduction of diaphragmatic force caused by CMV compared to CON was worsened with PSV and SBT (both p < 0.05 vs. CON and CMV). Both PSV and SBT reversed oxidative stress and calpain-1 activation caused by CMV. Reduced pAKT/AKT was observed after CMV and both weaning procedures. CONCLUSIONS MV resulted in a loss of diaphragmatic contractility, which was aggravated in SBT and PSV despite reversal of oxidative stress and proteolysis.
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Affiliation(s)
- Christian S Bruells
- Department of Intensive and Intermediate Care, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany.
| | - Thomas Breuer
- Department of Intensive and Intermediate Care, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany. .,Department of Anaesthesiology, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany.
| | - Karen Maes
- Laboratory of Pneumology, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Ingmar Bergs
- Department of Anaesthesiology, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Christian Bleilevens
- Department of Anaesthesiology, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Gernot Marx
- Department of Intensive and Intermediate Care, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Joachim Weis
- Institute of Neuropathology, University Hospital of the RWTH Aachen, Aachen, Germany
| | | | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
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Ambrosino N, Casaburi R, Chetta A, Clini E, Donner CF, Dreher M, Goldstein R, Jubran A, Nici L, Owen CA, Rochester C, Tobin MJ, Vagheggini G, Vitacca M, ZuWallack R. 8th International conference on management and rehabilitation of chronic respiratory failure: the long summaries – Part 3. Multidiscip Respir Med 2015. [PMCID: PMC4595187 DOI: 10.1186/s40248-015-0028-x] [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: 11/26/2022] Open
Abstract
This paper summarizes the Part 3 of the proceedings of the 8th International Conference on Management and Rehabilitation of Chronic Respiratory Failure, held in Pescara, Italy, on 7 and 8 May, 2015. It summarizes the contributions from numerous experts in the field of chronic respiratory disease and chronic respiratory failure. The outline follows the temporal sequence of presentations. This paper (Part 3) presents a section regarding Moving Across the Spectrum of Care for Long-Term Ventilation (Moving Across the Spectrum of Care for Long-Term Ventilation, New Indications for Non-Invasive Ventilation, Elective Ventilation in Respiratory Failure - Can you Prevent ICU Care in Patients with COPD?, Weaning in Long-Term Acute Care Hospitals in the United States, The Difficult-to-Wean Patient: Comprehensive management, Telemonitoring in Ventilator-Dependent Patients, Ethics and Palliative Care in Critically-Ill Respiratory Patients, and Ethics and Palliative Care in Ventilator-Dependent Patients).
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15
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Abstract
Purpose of review Compared with the conventional forms of partial support, neurally adjusted ventilatory assist was repeatedly shown to improve patient–ventilator synchrony and reduce the risk of overassistance, while guaranteeing adequate inspiratory effort and gas exchange. A few animal studies also suggested the potential of neurally adjusted ventilatory assist in averting the risk of ventilator-induced lung injury. Recent work adds new information on the physiological effects of neurally adjusted ventilatory assist. Recent findings Compared with pressure support, neurally adjusted ventilatory assist has been shown to improve patient–ventilator interaction and synchrony in patients with the most challenging respiratory system mechanics, such as very low compliance consequent to severe acute respiratory distress syndrome and high resistance and air trapping due to chronic airflow obstruction; enhance redistribution of the ventilation in the dependent lung regions; avert the risk of patient–ventilator asynchrony due to sedation; avoid central apneas; limit the risk of high (injurious) tidal volumes in patients with acute respiratory distress syndrome of varied severity; and improve patient–ventilator interaction and synchrony during noninvasive ventilation, irrespective of the interface utilized. Summary Several studies nowadays prove the physiological benefits of neurally adjusted ventilatory assist, as opposed to the conventional modes of partial support. Whether these advantages translate into improvement of clinical outcomes remains to be determined.
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Abstract
Identification and adoption of strategies to promote timely and successful weaning from mechanical ventilation remain a research and quality improvement priority. The most important steps in the weaning process to prevent unnecessary prolongation of mechanical ventilation are timely recognition of both readiness to wean and readiness to extubate. Strategies shown to be effective in promoting timely weaning include weaning protocols and use of spontaneous breathing trials. This review explores various other strategies that also may promote timely and successful weaning including bundling of spontaneous breathing trials with sedation and delirium monitoring/management as well as early mobility, the use of automated weaning systems and modes that improve patient-ventilator interaction, mechanical insufflation-exsufflation as a weaning adjunct, early extubation to non-invasive ventilation and high flow humidified oxygen. As most critically ill patients requiring mechanical ventilation will tolerate extubation with minimal weaning, identification of strategies to improve management of those patients experiencing difficult and prolonged weaning should be a priority for clinical practice, quality improvement initiatives and weaning research.
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Affiliation(s)
- Louise Rose
- Critical Care Research, Sunnybrook Health Sciences Centre, Canada; Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Canada; Provincial Centre of Weaning Excellence, Toronto East General Hospital, Canada; Institute for Clinical Evaluative Sciences, Canada; Li Ka Shing Institute, St Michael's Hospital, Canada; West Park Healthcare Centre, Canada; Canadian Institutes of Health Research (CIHR) New Investigator, Canada.
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Garzando M, Ferrandis R, Garrigues B, Soro M, Belda FJ. Neurally adjusted ventilatory assist: An update. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2014. [DOI: 10.1016/j.tacc.2014.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Suarez-Sipmann F. New modes of assisted mechanical ventilation. Med Intensiva 2014; 38:249-60. [PMID: 24507472 DOI: 10.1016/j.medin.2013.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 10/22/2013] [Accepted: 10/27/2013] [Indexed: 10/25/2022]
Abstract
Recent major advances in mechanical ventilation have resulted in new exciting modes of assisted ventilation. Compared to traditional ventilation modes such as assisted-controlled ventilation or pressure support ventilation, these new modes offer a number of physiological advantages derived from the improved patient control over the ventilator. By implementing advanced closed-loop control systems and using information on lung mechanics, respiratory muscle function and respiratory drive, these modes are specifically designed to improve patient-ventilator synchrony and reduce the work of breathing. Depending on their specific operational characteristics, these modes can assist spontaneous breathing efforts synchronically in time and magnitude, adapt to changing patient demands, implement automated weaning protocols, and introduce a more physiological variability in the breathing pattern. Clinicians have now the possibility to individualize and optimize ventilatory assistance during the complex transition from fully controlled to spontaneous assisted ventilation. The growing evidence of the physiological and clinical benefits of these new modes is favoring their progressive introduction into clinical practice. Future clinical trials should improve our understanding of these modes and help determine whether the claimed benefits result in better outcomes.
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Affiliation(s)
- F Suarez-Sipmann
- Servicio de Medicina Intensiva, Hospital Universitario de Uppsala, Laboratorio Hedenstierna, Departamento de Ciencias Quirúrgicas, Universidad de Uppsala, Uppsala, Suecia.
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