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Jackson R, Kim A, Moroz N, Damiani LF, Grieco DL, Piraino T, Friedrich JO, Mercat A, Telias I, Brochard LJ. Reverse triggering ? a novel or previously missed phenomenon? Ann Intensive Care 2024; 14:78. [PMID: 38776032 PMCID: PMC11111438 DOI: 10.1186/s13613-024-01303-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 04/27/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Reverse triggering (RT) was described in 2013 as a form of patient-ventilator asynchrony, where patient's respiratory effort follows mechanical insufflation. Diagnosis requires esophageal pressure (Pes) or diaphragmatic electrical activity (EAdi), but RT can also be diagnosed using standard ventilator waveforms. HYPOTHESIS We wondered (1) how frequently RT would be present but undetected in the figures from literature, especially before 2013; (2) whether it would be more prevalent in the era of small tidal volumes after 2000. METHODS We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials, from 1950 to 2017, with key words related to asynchrony to identify papers with figures including ventilator waveforms expected to display RT if present. Experts labelled waveforms. 'Definite' RT was identified when Pes or EAdi were in the tracing, and 'possible' RT when only flow and pressure waveforms were present. Expert assessment was compared to the author's descriptions of waveforms. RESULTS We found 65 appropriate papers published from 1977 to now, containing 181 ventilator waveforms. 21 cases of 'possible' RT and 25 cases of 'definite' RT were identified by the experts. 18.8% of waveforms prior to 2013 had evidence of RT. Most cases were published after 2000 (1 before vs. 45 after, p = 0.03). 54% of RT cases were attributed to different phenomena. A few cases of identified RT were already described prior to 2013 using different terminology (earliest in 1997). While RT cases attributed to different phenomena decreased after 2013, 60% of 'possible' RT remained missed. CONCLUSION RT has been present in the literature as early as 1997, but most cases were found after the introduction of low tidal volume ventilation in 2000. Following 2013, the number of undetected cases decreased, but RT are still commonly missed. Reverse Triggering, A Missed Phenomenon in the Literature. Critical Care Canada Forum 2019 Abstracts. Can J Anesth/J Can Anesth 67 (Suppl 1), 1-162 (2020). https://doi-org.myaccess.library.utoronto.ca/ https://doi.org/10.1007/s12630-019-01552-z .
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Affiliation(s)
- Robert Jackson
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute and St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Audery Kim
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute and St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Nikolay Moroz
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute and St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Department of Respiratory Therapy, McGill University Health Centre, Montreal, QC, Canada
| | - L Felipe Damiani
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute and St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Departamento Ciencias de la Salud, Carrera de Kinesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Domenico Luca Grieco
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute and St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Anesthesia, Italy
- Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Thomas Piraino
- Department of Anesthesia, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Jan O Friedrich
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute and St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Alain Mercat
- Medical ICU and Vent'Lab, University Hospital of Angers, University of Angers, 4 Rue Larrey, Angers Cedex 9, 49933, France
| | - Irene Telias
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute and St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Laurent J Brochard
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute and St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
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Zimmerman KO, Smith PB, Benjamin DK, Laughon M, Clark R, Traube C, Stürmer T, Hornik CP. Sedation, Analgesia, and Paralysis during Mechanical Ventilation of Premature Infants. J Pediatr 2017; 180:99-104.e1. [PMID: 27522446 PMCID: PMC5183489 DOI: 10.1016/j.jpeds.2016.07.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 05/31/2016] [Accepted: 07/01/2016] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To characterize administration of sedatives, analgesics, and paralytics in a large cohort of mechanically ventilated premature infants. STUDY DESIGN Retrospective cohort study including all infants <1500 g birth weight and <32 weeks gestational age (GA) mechanically ventilated at 348 Pediatrix Medical Group neonatal intensive care units from 1997 to 2012. The primary outcome is the proportion of mechanically ventilated days in which infants were administered drugs of interest. Multivariable logistic regression was used to evaluate the predictors of administration of drugs of interest. RESULTS We identified 85 911 mechanically ventilated infants. Infants received a drug of interest (opioids, benzodiazepines, other sedatives, and paralytics) on 433 587/1 305 413 (33%) of mechanically ventilated infant days. The administration of opioids increased during the study period from 5% of infant days in 1997 to 32% in 2012. The administration of benzodiazepines increased during the study period from 5% of infant days in 1997 to 24% in 2012. Use of paralytics and other drugs remained ≤1% throughout the study period. Predictors of drug administration included younger GA, small for GA status, male sex, presence of a major congenital anomaly, older postnatal age at intubation, exposure to high-frequency ventilation, exposure to inotropes, more recent year of discharge, and neonatal intensive care unit site. CONCLUSIONS Administration of opioids and benzodiazepines in mechanically ventilated premature infants increased over time. Because infant characteristics were unchanged, site-specific differences in practice likely explain our observations. Increased administration over time is concerning given limited evidence of benefit and potential for harm.
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Affiliation(s)
- Kanecia O Zimmerman
- Department of Pediatrics, Duke Clinical Research Institute, Duke University, Durham, NC
| | - P Brian Smith
- Department of Pediatrics, Duke Clinical Research Institute, Duke University, Durham, NC
| | | | - Matthew Laughon
- Department of Pediatrics, Division of Neonatology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Reese Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL
| | - Chani Traube
- Department of Pediatrics, Division of Critical Care Medicine, Weill Cornell Medical College, New York, NY
| | - Til Stürmer
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Christoph P Hornik
- Department of Pediatrics, Duke Clinical Research Institute, Duke University, Durham, NC.
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Patthum A, Peters M, Lockwood C. Effectiveness and safety of Neurally Adjusted Ventilatory Assist (NAVA) mechanical ventilation compared to standard conventional mechanical ventilation in optimizing patient-ventilator synchrony in critically ill patients: a systematic review protocol. ACTA ACUST UNITED AC 2015; 13:31-46. [PMID: 26447047 DOI: 10.11124/jbisrir-2015-1914] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Revised: 09/12/2014] [Accepted: 09/18/2014] [Indexed: 10/31/2022]
Affiliation(s)
- Arisara Patthum
- Faculty of Health Sciences, Joanna Briggs Institute, University of Adelaide, South Australia.,Lyell McEwin Hospital, Adelaide, South Australia
| | - Micah Peters
- Faculty of Health Sciences, Joanna Briggs Institute, University of Adelaide, South Australia
| | - Craig Lockwood
- Faculty of Health Sciences, Joanna Briggs Institute, University of Adelaide, South Australia
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Mellott KG, Grap MJ, Munro CL, Sessler CN, Wetzel PA, Nilsestuen JO, Ketchum JM. Patient ventilator asynchrony in critically ill adults: frequency and types. Heart Lung 2014; 43:231-43. [PMID: 24794784 DOI: 10.1016/j.hrtlng.2014.02.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Revised: 01/31/2014] [Accepted: 02/03/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patient ventilator asynchrony (PVA) occurs frequently, but little is known about the types and frequency of PVA. Asynchrony is associated with significant patient discomfort, distress and poor clinical outcomes (duration of mechanical ventilation, intensive care unit and hospital stay). METHODS Pressure-time and flow-time waveform data were collected on 27 ICU patients using the Noninvasive Cardiac Output monitor for up to 90 min per subject and blinded waveform analysis was performed. RESULTS PVA occurred during all phases of ventilated breaths and all modes of ventilation. The most common type of PVA was Ineffective Trigger. Ineffective trigger occurs when the patient's own breath effort will not trigger a ventilator breath. The overall frequency of asynchronous breaths in the sample was 23%, however 93% of the sample experienced at least one incident of PVA during their observation period. Seventy-seven percent of subjects experienced multiple types of PVA. CONCLUSIONS PVA occurs frequently in a variety of types although the majority of PVA is ineffective trigger. The study uncovered previously unidentified waveforms that may indicate that there is a greater range of PVAs than previously reported. Newly described PVA, in particular, PVA combined in one breath, may signify substantial patient distress or poor physiological circumstance that clinicians should investigate.
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Affiliation(s)
- Karen G Mellott
- Department of Acute and Continuing Care, School of Nursing, University of Texas Health, Health Science Center at Houston, 6901 Bertner Avenue, Houston, TX 77030, USA.
| | - Mary Jo Grap
- Department of Adult Health and Nursing Systems, School of Nursing, Virginia Commonwealth University, 1100 East Leigh St., P.O. Box 980567, Richmond, VA 23298-0567, USA
| | - Cindy L Munro
- Research and Innovation, College of Nursing, University of Southern Florida, 12901 Bruce B. Downs Blvd. MDC Box 22, Tampa, FL 33612, USA
| | - Curtis N Sessler
- Division of Pulmonary Disease and Critical Care Medicine, School of Medicine, Virginia Commonwealth University, P.O. Box 980050, Richmond, VA 23298-0050, USA
| | - Paul A Wetzel
- Department of Biomedical Engineering, School of Engineering, Virginia Commonwealth University, P.O. Box 843067, Richmond, VA 23284-3067, USA
| | - Jon O Nilsestuen
- Department of Respiratory Therapy, School of Allied Health Sciences, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-1146, USA
| | - Jessica M Ketchum
- Department of Biostatistics, School of Medicine, Virginia Commonwealth University, P.O. Box 980032, Richmond, VA 23298-0032, USA
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Mellott KG, Grap MJ, Munro CL, Sessler CN, Wetzel PA. Patient-ventilator dyssynchrony: clinical significance and implications for practice. Crit Care Nurse 2009; 29:41-55 quiz 1 p following 55. [PMID: 19724065 DOI: 10.4037/ccn2009612] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Karen G Mellott
- Virginia Commonwealth University in Richmond, Richmond, VA 23298-0567, USA.
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MacDonald SM, Song G, Poon CS. Nonassociative learning promotes respiratory entrainment to mechanical ventilation. PLoS One 2007; 2:e865. [PMID: 17848996 PMCID: PMC1959120 DOI: 10.1371/journal.pone.0000865] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2007] [Accepted: 08/09/2007] [Indexed: 12/03/2022] Open
Abstract
Background Patient-ventilator synchrony is a major concern in critical care and is influenced by phasic lung-volume feedback control of the respiratory rhythm. Routine clinical application of positive end-expiratory pressure (PEEP) introduces a tonic input which, if unopposed, might disrupt respiratory-ventilator entrainment through sustained activation of the vagally-mediated Hering-Breuer reflex. We suggest that this potential adverse effect may be averted by two differentiator forms of nonassociative learning (habituation and desensitization) of the Hering-Breuer reflex via pontomedullary pathways. Methodology/Principal Findings We tested these hypotheses in 17 urethane-anesthetized adult Sprague-Dawley rats under controlled mechanical ventilation. Without PEEP, phrenic discharge was entrained 1∶1 to the ventilator rhythm. Application of PEEP momentarily dampened the entrainment to higher ratios but this effect was gradually adapted by nonassociative learning. Bilateral electrolytic lesions of the pneumotaxic center weakened the adaptation to PEEP, whereas sustained stimulation of the pneumotaxic center weakened the entrainment independent of PEEP. In all cases, entrainment was abolished after vagotomy. Conclusions/Significance Our results demonstrate an important functional role for pneumotaxic desensitization and extra-pontine habituation of the Hering-Breuer reflex elicited by lung inflation: acting as buffers or high-pass filters against tonic vagal volume input, these differentiator forms of nonassociative learning help to restore respiratory-ventilator entrainment in the face of PEEP. Such central sites-specific habituation and desensitization of the Hering-Breuer reflex provide a useful experimental model of nonassociative learning in mammals that is of particular significance in understanding respiratory rhythmogenesis and coupled-oscillator entrainment mechanisms, and in the clinical management of mechanical ventilation in respiratory failure.
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Affiliation(s)
- Shawna M. MacDonald
- Harvard-Massachusetts Institute of Technology Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
| | - Gang Song
- Harvard-Massachusetts Institute of Technology Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
| | - Chi-Sang Poon
- Harvard-Massachusetts Institute of Technology Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
- * To whom correspondence should be addressed. E-mail:
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Abstract
Although the effective evaluation and management of agitated patients often receives less attention than other aspects of critical illness, it is among the most important and rewarding challenges that face critical care physicians. Key features of effective management include a thorough, organized search for potentially dangerous and correctable causes; a sound understanding of the pharmacology of analgesics and sedatives; and keeping a steady eye on appropriate management goals. In turn, the reward for excellent care will be shorter lengths of stay, more rapid liberation from mechanical ventilation, improved cognition, cost savings, and, perhaps, improved survival.
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Affiliation(s)
- Mark D Siegel
- Pulmonary and Critical Care Section, Yale University School of Medicine, Medical Intensive Care Unit, Yale-New Haven Hospital, New Haven, CT, USA.
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Gorini M, Villella G, Ginanni R, Augustynen A, Tozzi D, Corrado A. Effect of assist negative pressure ventilation by microprocessor based iron lung on breathing effort. Thorax 2002; 57:258-62. [PMID: 11867832 PMCID: PMC1746266 DOI: 10.1136/thorax.57.3.258] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The lack of patient triggering capability during negative pressure ventilation (NPV) may contribute to poor patient synchrony and induction of upper airway collapse. This study was undertaken to evaluate the performance of a microprocessor based iron lung capable of thermistor triggering. METHODS The effects of NPV with thermistor triggering were studied in four normal subjects and six patients with an acute exacerbation of chronic obstructive pulmonary disease (COPD) by measuring: (1) the time delay (TDtr) between the onset of inspiratory airflow and the start of assisted breathing; (2) the pressure-time product of the diaphragm (PTPdi); and (3) non-triggering inspiratory efforts (NonTrEf). In patients the effects of negative extrathoracic end expiratory pressure (NEEP) added to NPV were also evaluated. RESULTS With increasing trigger sensitivity the mean (SE) TDtr ranged from 0.29 (0.02) s to 0.21 (0.01) s (mean difference 0.08 s, 95% CI 0.05 to 0.12) in normal subjects and from 0.30 (0.02) s to 0.21 (0.01) s (mean difference 0.09 s, 95% CI 0.06 to 0.12) in patients with COPD; NonTrEf ranged from 8.2 (1.8)% to 1.2 (0.1)% of the total breaths in normal subjects and from 11.8 (2.2)% to 2.5 (0.4)% in patients with COPD. Compared with spontaneous breathing, PTPdi decreased significantly with NPV both in normal subjects and in patients with COPD. NEEP added to NPV resulted in a significant decrease in dynamic intrinsic PEEP, diaphragm effort exerted in the pre-trigger phase, and NonTrEf. CONCLUSIONS Microprocessor based iron lung capable of thermistor triggering was able to perform assist NPV with acceptable TDtr, significant unloading of the diaphragm, and a low rate of NonTrEf. NEEP added to NPV improved the synchrony between the patient and the ventilator.
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Affiliation(s)
- M Gorini
- Respiratory Intensive Care Unit, Careggi Hospital, Firenze, Italy.
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Gorini M, Corrado A, Villella G, Ginanni R, Augustynen A, Tozzi D. Physiologic effects of negative pressure ventilation in acute exacerbation of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2001; 163:1614-8. [PMID: 11401883 DOI: 10.1164/ajrccm.163.7.2012079] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
To assess the physiologic effects of continuous negative extrathoracic pressure (CNEP), negative pressure ventilation (NPV), and negative extrathoracic end-expiratory pressure (NEEP) added to NPV in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD), we measured in seven patients ventilatory pattern, arterial blood gases, respiratory mechanics, and pressure- time product of the diaphragm (PTPdi) under four conditions: (1) spontaneous breathing (SB); (2) CNEP (-5 cm H(2)O); (3) NPV; (4) NPV plus NEEP. CNEP and NPV were provided by a microprocessor-based iron lung capable of thermistor-triggering. Compared with SB, CNEP improved slightly but significantly Pa(CO(2 ))and pH, and decreased PTPdi (388 +/- 59 versus 302 +/- 43 cm H(2)O. s, respectively, p < 0.05) and dynamic intrinsic positive end-expiratory pressure (PEEPi) (4.6 +/- 0.5 versus 2.1 +/- 0.3 cm H(2)O, respectively, p < 0.001). NPV increased minute ventilation (V E), improved arterial blood gases, and decreased PTPdi to 34% of value during SB (p < 0.001). NEEP added to NPV further slightly decreased PTPdi and improved patient-ventilator interaction by reducing dynamic PEEPi and nontriggering inspiratory efforts. We conclude that CNEP and NPV, provided by microprocessor-based iron lung, are able to improve ventilatory pattern and arterial blood gases, and to unload inspiratory muscles in patients with acute exacerbation of COPD.
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Affiliation(s)
- M Gorini
- Respiratory Intensive Care Unit, Careggi Hospital, Florence, Italy.
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