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Spinelli E, Pesenti A, Slobod D, Fornari C, Fumagalli R, Grasselli G, Volta CA, Foti G, Navalesi P, Knafelj R, Pelosi P, Mancebo J, Brochard L, Mauri T. Clinical risk factors for increased respiratory drive in intubated hypoxemic patients. Crit Care 2023; 27:138. [PMID: 37041553 PMCID: PMC10088111 DOI: 10.1186/s13054-023-04402-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 03/14/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND There is very limited evidence identifying factors that increase respiratory drive in hypoxemic intubated patients. Most physiological determinants of respiratory drive cannot be directly assessed at the bedside (e.g., neural inputs from chemo- or mechano-receptors), but clinical risk factors commonly measured in intubated patients could be correlated with increased drive. We aimed to identify clinical risk factors independently associated with increased respiratory drive in intubated hypoxemic patients. METHODS We analyzed the physiological dataset from a multicenter trial on intubated hypoxemic patients on pressure support (PS). Patients with simultaneous assessment of the inspiratory drop in airway pressure at 0.1-s during an occlusion (P0.1) and risk factors for increased respiratory drive on day 1 were included. We evaluated the independent correlation of the following clinical risk factors for increased drive with P0.1: severity of lung injury (unilateral vs. bilateral pulmonary infiltrates, PaO2/FiO2, ventilatory ratio); arterial blood gases (PaO2, PaCO2 and pHa); sedation (RASS score and drug type); SOFA score; arterial lactate; ventilation settings (PEEP, level of PS, addition of sigh breaths). RESULTS Two-hundred seventeen patients were included. Clinical risk factors independently correlated with higher P0.1 were bilateral infiltrates (increase ratio [IR] 1.233, 95%CI 1.047-1.451, p = 0.012); lower PaO2/FiO2 (IR 0.998, 95%CI 0.997-0.999, p = 0.004); higher ventilatory ratio (IR 1.538, 95%CI 1.267-1.867, p < 0.001); lower pHa (IR 0.104, 95%CI 0.024-0.464, p = 0.003). Higher PEEP was correlated with lower P0.1 (IR 0.951, 95%CI 0.921-0.982, p = 0.002), while sedation depth and drugs were not associated with P0.1. CONCLUSIONS Independent clinical risk factors for higher respiratory drive in intubated hypoxemic patients include the extent of lung edema and of ventilation-perfusion mismatch, lower pHa, and lower PEEP, while sedation strategy does not affect drive. These data underline the multifactorial nature of increased respiratory drive.
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Affiliation(s)
- Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonio Pesenti
- 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
| | - Douglas Slobod
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Critical Care Medicine, McGill University, Montreal, QC, Canada
| | - Carla Fornari
- Research Centre On Public Health, University of Milano - Bicocca, Monza, Italy
| | - Roberto Fumagalli
- Anesthesia and Critical Care Service 1, Niguarda Hospital, Milan, Italy
| | - 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
| | - Carlo Alberto Volta
- Morphology, Surgery and Experimental Medicine, Anesthesia and Intensive Care Unit, University of Ferrara, Ferrara, Italy
| | - Giuseppe Foti
- Anesthesia and Critical Care, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Paolo Navalesi
- Anesthesia and Intensive Care, Department of Medicine - DIMED, Padua University Hospital, University of Padua, Padua, Italy
| | - Rihard Knafelj
- Center for Internal Intensive Medicine (MICU), University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Jordi Mancebo
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Tommaso Mauri
- 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.
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2
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Koopman AA, van Dijk J, Oppersma E, Blokpoel RGT, Kneyber MCJ. Surface electromyography to quantify neuro-respiratory drive and neuro-mechanical coupling in mechanically ventilated children. Respir Res 2023; 24:77. [PMID: 36915106 PMCID: PMC10010013 DOI: 10.1186/s12931-023-02374-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/22/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND The patient's neuro-respiratory drive, measured as electrical activity of the diaphragm (EAdi), quantifies the mechanical load on the respiratory muscles. It correlates with respiratory effort but requires a dedicated esophageal catheter. Transcutaneous (surface) monitoring of respiratory muscle electromyographic (sEMG) signals may be considered a suitable alternative to EAdi because of its non-invasive character, with the additional benefit that it allows for simultaneously monitoring of other respiratory muscles. We therefore sought to study the neuro-respiratory drive and timing of inspiratory muscles using sEMG in a cohort of children enrolled in a pediatric ventilation liberation trial. The neuro-mechanical coupling, relating the pressure generated by the inspiratory muscles to the sEMG signals of these muscles, was also calculated. METHODS This is a secondary analysis of data from a randomized cross-over trial in ventilated patients aged < 5 years. sEMG recordings of the diaphragm and parasternal intercostal muscles (ICM), esophageal pressure tracings and ventilator scalars were simultaneously recorded during continuous spontaneous ventilation and pressure controlled-intermittent mandatory ventilation, and at three levels of pressure support. Neuro-respiratory drive, timing of diaphragm and ICM relative to the mechanical ventilator's inspiration and neuro-mechanical coupling were quantified. RESULTS Twenty-nine patients were included (median age: 5.9 months). In response to decreasing pressure support, both amplitude of sEMG (diaphragm: p = 0.001 and ICM: p = 0.002) and neuro-mechanical efficiency indices increased (diaphragm: p = 0.05 and ICM: p < 0.001). Poor correlations between neuro-respiratory drive and respiratory effort were found, with R2: 0.088 [0.021-0.152]. CONCLUSIONS sEMG allows for the quantification of the electrical activity of the diaphragm and ICM in mechanically ventilated children. Both neuro-respiratory drive and neuro-mechanical efficiency increased in response to lower inspiratory assistance. There was poor correlation between neuro-respiratory drive and respiratory effort. TRIAL REGISTRATION ClinicalTrials.gov ID NCT05254691. Registered 24 February 2022, registered retrospectively.
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Affiliation(s)
- Alette A Koopman
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
| | - Jefta van Dijk
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Eline Oppersma
- Cardiovascular and Respiratory Physiology Group, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Robert G T Blokpoel
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Martin C J Kneyber
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.,Critical Care, Anaesthesiology, Peri-Operative & Emergency Medicine (CAPE), University of Groningen, Groningen, The Netherlands
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Viegas P, Ageno E, Corsi G, Tagariello F, Razakamanantsoa L, Vilde R, Ribeiro C, Heunks L, Patout M, Fisser C. Highlights from the Respiratory Failure and Mechanical Ventilation 2022 Conference. ERJ Open Res 2023; 9:00467-2022. [PMID: 36949961 PMCID: PMC10026011 DOI: 10.1183/23120541.00467-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 11/10/2022] [Indexed: 11/25/2022] Open
Abstract
The Respiratory Intensive Care Assembly of the European Respiratory Society gathered in Berlin to organise the second Respiratory Failure and Mechanical Ventilation Conference in June 2022. The conference covered several key points of acute and chronic respiratory failure in adults. During the 3-day conference, ventilatory strategies, patient selection, diagnostic approaches, treatment and health-related quality of life topics were addressed by a panel of international experts. Lectures delivered during the event have been summarised by Early Career Members of the Assembly and take-home messages highlighted.
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Affiliation(s)
- Pedro Viegas
- Pulmonology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Elisa Ageno
- Respiratory and Critical Care Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, University Hospital Sant'Orsola-Malpighi, Bologna, Italy
- Department of Clinical, Integrated and Experimental Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Gabriele Corsi
- Respiratory and Critical Care Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, University Hospital Sant'Orsola-Malpighi, Bologna, Italy
- Department of Clinical, Integrated and Experimental Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Federico Tagariello
- Respiratory and Critical Care Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, University Hospital Sant'Orsola-Malpighi, Bologna, Italy
- Department of Clinical, Integrated and Experimental Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Léa Razakamanantsoa
- Unité Ambulatoire d'Appareillage Respiratoire de Domicile (UAARD), Service de Pneumologie (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Paris, France
| | - Rudolfs Vilde
- Centre of Pulmonology and Thoracic Surgery, Pauls Stradiņš Clinical University Hospital, Riga, Latvia
- Riga Stradiņš University, Riga, Latvia
| | - Carla Ribeiro
- Pulmonology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Leo Heunks
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Maxime Patout
- Service des Pathologies du Sommeil (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Christoph Fisser
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
- Corresponding author: Christoph Fisser ()
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Dreyfus L, Butin M, Plaisant F, Claris O, Baudin F. Respiratory physiology during NAVA ventilation in neonates born with a congenital diaphragmatic hernia: The "NAVA-diaph" pilot study. Pediatr Pulmonol 2023; 58:1542-1550. [PMID: 36807570 DOI: 10.1002/ppul.26357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 02/07/2023] [Accepted: 02/13/2023] [Indexed: 02/20/2023]
Abstract
BACKGROUND Neurally adjusted ventilatory assist (NAVA) is a ventilatory mode that delivers synchronized ventilation, proportional to the electrical activity of the diaphragm (EAdi). Although it has been proposed in infants with a congenital diaphragmatic hernia (CDH), the diaphragmatic defect and the surgical repair could alter the physiology of the diaphragm. AIM To evaluate, in a pilot study, the relationship between the respiratory drive (EAdi) and the respiratory effort in neonates with CDH during the postsurgical period under either NAVA ventilation or conventional ventilation (CV). METHODS This prospective physiological study included eight neonates admitted to a neonatal intensive care unit with a diagnosis of CDH. EAdi, esophageal, gastric, and transdiaphragmatic pressure, as well as clinical parameters, were recorded during NAVA and CV (synchronized intermittent mandatory pressure ventilation) in the postsurgical period. RESULTS EAdi was detectable and there was a correlation between the ΔEAdi (maximal - minimal values) and the transdiaphragmatic pressure (r = 0.26, 95% confidence interval [CI] [0.222; 0.299]). There was no significant difference in terms of clinical or physiological parameters during NAVA compared to CV, including work of breathing. CONCLUSION Respiratory drive and effort were correlated in infants with CDH and therefore NAVA is a suitable proportional mode in this population. EAdi can also be used to monitor the diaphragm for individualized support.
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Affiliation(s)
- Lélia Dreyfus
- Service de Néonatologie et Réanimation Néonatale, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France
| | - Marine Butin
- Service de Néonatologie et Réanimation Néonatale, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France
- Centre International de Recherche en infectiologie (CIRI), Team "Pathogénie des Staphylocoques", CNRS, UMR5308, ENS de Lyon, Inserm, U1111, Université Claude Bernard Lyon 1, Lyon, France
| | - Frank Plaisant
- Service de Néonatologie et Réanimation Néonatale, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France
| | - Olivier Claris
- Service de Néonatologie et Réanimation Néonatale, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France
- EA 419, Université Claude Bernard Lyon 1, Villeurbanne, France
| | - Florent Baudin
- Service de réanimation pédiatrique, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France
- Unité APCSe (UP 2021, A101), Universités de Lyon, VetAgro Sup, Marcy l'Etoile, France
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5
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Soundoulounaki S, Sylligardos E, Akoumianaki E, Sigalas M, Kondili E, Georgopoulos D, Trahanias P, Vaporidi K. Neural Network-Enabled Identification of Weak Inspiratory Efforts during Pressure Support Ventilation Using Ventilator Waveforms. J Pers Med 2023; 13:jpm13020347. [PMID: 36836581 PMCID: PMC9966968 DOI: 10.3390/jpm13020347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 02/10/2023] [Accepted: 02/15/2023] [Indexed: 02/19/2023] Open
Abstract
During pressure support ventilation (PSV), excessive assist results in weak inspiratory efforts and promotes diaphragm atrophy and delayed weaning. The aim of this study was to develop a classifier using a neural network to identify weak inspiratory efforts during PSV, based on the ventilator waveforms. Recordings of flow, airway, esophageal and gastric pressures from critically ill patients were used to create an annotated dataset, using data from 37 patients at 2-5 different levels of support, computing the inspiratory time and effort for every breath. The complete dataset was randomly split, and data from 22 patients (45,650 breaths) were used to develop the model. Using a One-Dimensional Convolutional Neural Network, a predictive model was developed to characterize the inspiratory effort of each breath as weak or not, using a threshold of 50 cmH2O*s/min. The following results were produced by implementing the model on data from 15 different patients (31,343 breaths). The model predicted weak inspiratory efforts with a sensitivity of 88%, specificity of 72%, positive predictive value of 40%, and negative predictive value of 96%. These results provide a 'proof-of-concept' for the ability of such a neural-network based predictive model to facilitate the implementation of personalized assisted ventilation.
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Affiliation(s)
- Stella Soundoulounaki
- Department of Intensive Care Medicine, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Emmanouil Sylligardos
- Institute of Computer Science, Foundation for Research and Technology—Hellas (FORTH), 70013 Heraklion, Greece
- Department of Computer Science, University of Crete, 70013 Heraklion, Greece
| | - Evangelia Akoumianaki
- Department of Intensive Care Medicine, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Markos Sigalas
- Institute of Computer Science, Foundation for Research and Technology—Hellas (FORTH), 70013 Heraklion, Greece
| | - Eumorfia Kondili
- Department of Intensive Care Medicine, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Dimitrios Georgopoulos
- Department of Intensive Care Medicine, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Panos Trahanias
- Institute of Computer Science, Foundation for Research and Technology—Hellas (FORTH), 70013 Heraklion, Greece
- Department of Computer Science, University of Crete, 70013 Heraklion, Greece
| | - Katerina Vaporidi
- Department of Intensive Care Medicine, School of Medicine, University of Crete, 71003 Heraklion, Greece
- Correspondence:
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van Diepen A, Bakkes THGF, De Bie AJR, Turco S, Bouwman RA, Woerlee PH, Mischi M. Evaluation of the accuracy of established patient inspiratory effort estimation methods during mechanical support ventilation. Heliyon 2023; 9:e13610. [PMID: 36852019 PMCID: PMC9958297 DOI: 10.1016/j.heliyon.2023.e13610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/13/2022] [Accepted: 02/06/2023] [Indexed: 02/12/2023] Open
Abstract
There is a clinical need for monitoring inspiratory effort to prevent lung- and diaphragm injury in patients who receive supportive mechanical ventilation in an Intensive Care Unit. Different pressure-based techniques are available to estimate this inspiratory effort at the bedside, but the accuracy of their effort estimation is uncertain since they are all based on a simplified linear model of the respiratory system, which omits gas compressibility of air, and the viscoelasticity and nonlinearities of the respiratory system. The aim of this in-silico study was to provide an overview of the pressure-based estimation techniques and to evaluate their accuracy using a more sophisticated model of the respiratory system and ventilator. The influence of the following parameters on the accuracy of the pressure-based estimation techniques was evaluated using the in-silico model: 1) the patient's respiratory mechanics 2) PEEP and the inspiratory pressure of the ventilator 3) gas compressibility of air 4) viscoelasticity of the respiratory system 5) the strength of the inspiratory effort. The best-performing technique in terms of accuracy was the whole breath occlusion. The average error and maximum error were the lowest for all patient archetypes. We found that the error was related to the expansion of gas in the breathing set and lungs and respiratory compliance. However, concerns exist that other factors not included in the model, such as a changed muscle-force relation during an occlusion, might influence the true accuracy. The estimation techniques based on the esophageal pressure showed an error related to the viscoelastic element in the model which leads to a higher error than the occlusion. The error of the esophageal pressure-based techniques is therefore highly dependent on the pathology of the patient and the settings of the ventilator and might change over time while a patient recovers or becomes more ill.
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Affiliation(s)
- A van Diepen
- Department of Electrical Engineering, Technische Universiteit Eindhoven, De Zaale, Eindhoven, 5612AZ, Noord-Brabant, the Netherlands
| | - T H G F Bakkes
- Department of Electrical Engineering, Technische Universiteit Eindhoven, De Zaale, Eindhoven, 5612AZ, Noord-Brabant, the Netherlands
| | - A J R De Bie
- Catharina Hospital, Michelangelolaan 2, Eindhoven, 5623 EJ, Noord-Brabant, the Netherlands
| | - S Turco
- Department of Electrical Engineering, Technische Universiteit Eindhoven, De Zaale, Eindhoven, 5612AZ, Noord-Brabant, the Netherlands
| | - R A Bouwman
- Department of Electrical Engineering, Technische Universiteit Eindhoven, De Zaale, Eindhoven, 5612AZ, Noord-Brabant, the Netherlands.,Catharina Hospital, Michelangelolaan 2, Eindhoven, 5623 EJ, Noord-Brabant, the Netherlands
| | - P H Woerlee
- Department of Electrical Engineering, Technische Universiteit Eindhoven, De Zaale, Eindhoven, 5612AZ, Noord-Brabant, the Netherlands
| | - M Mischi
- Department of Electrical Engineering, Technische Universiteit Eindhoven, De Zaale, Eindhoven, 5612AZ, Noord-Brabant, the Netherlands
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Umbrello M, Antonucci E, Muttini S. Neurally Adjusted Ventilatory Assist in Acute Respiratory Failure-A Narrative Review. J Clin Med 2022; 11:jcm11071863. [PMID: 35407471 PMCID: PMC9000024 DOI: 10.3390/jcm11071863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/10/2022] [Accepted: 03/25/2022] [Indexed: 02/08/2023] Open
Abstract
Maintaining spontaneous breathing has both potentially beneficial and deleterious consequences in patients with acute respiratory failure, depending on the balance that can be obtained between the protecting and damaging effects on the lungs and the diaphragm. Neurally adjusted ventilatory assist (NAVA) is an assist mode, which supplies the respiratory system with a pressure proportional to the integral of the electrical activity of the diaphragm. This proportional mode of ventilation has the theoretical potential to deliver lung- and respiratory-muscle-protective ventilation by preserving the physiologic defense mechanisms against both lung overdistention and ventilator overassistance, as well as reducing the incidence of diaphragm disuse atrophy while maintaining patient–ventilator synchrony. This narrative review presents an overview of NAVA technology, its basic principles, the different methods to set the assist level and the findings of experimental and clinical studies which focused on lung and diaphragm protection, machine–patient interaction and preservation of breathing pattern variability. A summary of the findings of the available clinical trials which investigate the use of NAVA in acute respiratory failure will also be presented and discussed.
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8
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Wu M, Yuan X, Liu L, Yang Y. Neurally Adjusted Ventilatory Assist vs. Conventional Mechanical Ventilation in Adults and Children With Acute Respiratory Failure: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2022; 9:814245. [PMID: 35273975 PMCID: PMC8901502 DOI: 10.3389/fmed.2022.814245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 01/20/2022] [Indexed: 11/13/2022] Open
Abstract
Background Patient-ventilator asynchrony is a common problem in mechanical ventilation (MV), resulting in increased complications of MV. Despite there being some pieces of evidence for the efficacy of improving the synchronization of neurally adjusted ventilatory assist (NAVA), controversy over its physiological and clinical outcomes remain. Herein, we conducted a systematic review and meta-analysis to determine the relative impact of NAVA or conventional mechanical ventilation (CMV) modes on the important outcomes of adults and children with acute respiratory failure (ARF). Methods Qualified studies were searched in PubMed, EMBASE, Medline, Web of Science, Cochrane Library, and additional quality evaluations up to October 5, 2021. The primary outcome was asynchrony index (AI); secondary outcomes contained the duration of MV, intensive care unit (ICU) mortality, the incidence rate of ventilator-associated pneumonia, pH, and Partial Pressure of Carbon Dioxide in Arterial Blood (PaCO2). A statistical heterogeneity for the outcomes was assessed using the I 2 test. A data analysis of outcomes using odds ratio (OR) for ICU mortality and ventilator-associated pneumonia incidence and mean difference (MD) for AI, duration of MV, pH, and PaCO2, with 95% confidence interval (CI), was expressed. Results Eighteen eligible studies (n = 926 patients) were eventually enrolled. For the primary outcome, NAVA may reduce the AI (MD = -18.31; 95% CI, -24.38 to -12.25; p < 0.001). For the secondary outcomes, the duration of MV in the NAVA mode was 2.64 days lower than other CMVs (MD = -2.64; 95% CI, -4.88 to -0.41; P = 0.02), and NAVA may decrease the ICU mortality (OR =0.60; 95% CI, 0.42 to 0.86; P = 0.006). There was no statistically significant difference in the incidence of ventilator-associated pneumonia, pH, and PaCO2 between NAVA and other MV modes. Conclusions Our study suggests that NAVA ameliorates the synchronization of patient-ventilator and improves the important clinical outcomes of patients with ARF compared with CMV modes.
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Affiliation(s)
- Mengfan Wu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Xueyan Yuan
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Ling Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
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9
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COVID-19 ARDS: Points to Be Considered in Mechanical Ventilation and Weaning. J Pers Med 2021; 11:jpm11111109. [PMID: 34834461 PMCID: PMC8618434 DOI: 10.3390/jpm11111109] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 12/21/2022] Open
Abstract
The COVID-19 disease can cause hypoxemic respiratory failure due to ARDS, requiring invasive mechanical ventilation. Although early studies reported that COVID-19-associated ARDS has distinctive features from ARDS of other causes, recent observational studies have demonstrated that ARDS related to COVID-19 shares common clinical characteristics and respiratory system mechanics with ARDS of other origins. Therefore, mechanical ventilation in these patients should be based on strategies aiming to mitigate ventilator-induced lung injury. Assisted mechanical ventilation should be applied early in the course of mechanical ventilation by considering evaluation and minimizing factors associated with patient-inflicted lung injury. Extracorporeal membrane oxygenation should be considered in selected patients with refractory hypoxia not responding to conventional ventilation strategies. This review highlights the current and evolving practice in managing mechanically ventilated patients with ARDS related to COVID-19.
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Haudebourg AF, Maraffi T, Tuffet S, Perier F, de Prost N, Razazi K, Mekontso Dessap A, Carteaux G. Refractory ineffective triggering during pressure support ventilation: effect of proportional assist ventilation with load-adjustable gain factors. Ann Intensive Care 2021; 11:147. [PMID: 34669080 PMCID: PMC8527439 DOI: 10.1186/s13613-021-00935-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 10/07/2021] [Indexed: 12/21/2022] Open
Abstract
Background Ineffective triggering is frequent during pressure support ventilation (PSV) and may persist despite ventilator adjustment, leading to refractory asynchrony. We aimed to assess the effect of proportional assist ventilation with load-adjustable gain factors (PAV+) on the occurrence of refractory ineffective triggering. Design Observational assessment followed by prospective cross-over physiological study. Setting Academic medical ICU. Patients Ineffective triggering was detected during PSV by a twice-daily inspection of the ventilator’s screen. The impact of pressure support level (PSL) adjustments on the occurrence of asynchrony was recorded. Patients experiencing refractory ineffective triggering, defined as persisting asynchrony at the lowest tolerated PSL, were included in the physiological study. Interventions Physiological study: Flow, airway, and esophageal pressures were continuously recorded during 10 min under PSV with the lowest tolerated PSL, and then under PAV+ with the gain adjusted to target a muscle pressure between 5 and 10 cmH2O. Measurements Primary endpoint was the comparison of asynchrony index between PSV and PAV+ after PSL and gain adjustments. Results Among 36 patients identified having ineffective triggering under PSV, 21 (58%) exhibited refractory ineffective triggering. The lowest tolerated PSL was higher in patients with refractory asynchrony as compared to patients with non-refractory ineffective triggering. Twelve out of the 21 patients with refractory ineffective triggering were included in the physiological study. The median lowest tolerated PSL was 17 cmH2O [12–18] with a PEEP of 7 cmH2O [5–8] and FiO2 of 40% [39–42]. The median gain during PAV+ was 73% [65–80]. The asynchrony index was significantly lower during PAV+ than PSV (2.7% [1.0–5.4] vs. 22.7% [10.3–40.1], p < 0.001) and consistently decreased in every patient with PAV+. Esophageal pressure–time product (PTPes) did not significantly differ between the two modes (107 cmH2O/s/min [79–131] under PSV vs. 149 cmH2O/s/min [129–170] under PAV+, p = 0.092), but the proportion of PTPes lost in ineffective triggering was significantly lower with PAV+ (2 cmH2O/s/min [1–6] vs. 8 cmH2O/s/min [3–30], p = 0.012). Conclusions Among patients with ineffective triggering under PSV, PSL adjustment failed to eliminate asynchrony in 58% of them (21 of 36 patients). In these patients with refractory ineffective triggering, switching from PSV to PAV+ significantly reduced or even suppressed the incidence of asynchrony. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00935-0.
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Affiliation(s)
- Anne-Fleur Haudebourg
- Service de Médecine Intensive Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France. .,Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France.
| | - Tommaso Maraffi
- Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France.,Service de Réanimation et Surveillance Continue Adulte, Centre hospitalier intercommunal de Créteil, 94000, Créteil, France
| | - Samuel Tuffet
- Service de Médecine Intensive Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France.,Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France.,Institut Mondor de Recherche Biomédicale INSERM 955, Créteil, France
| | - François Perier
- Service de Médecine Intensive Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France.,Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France
| | - Nicolas de Prost
- Service de Médecine Intensive Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France.,Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France
| | - Keyvan Razazi
- Service de Médecine Intensive Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France.,Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France
| | - Armand Mekontso Dessap
- Service de Médecine Intensive Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France.,Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France
| | - Guillaume Carteaux
- Service de Médecine Intensive Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France.,Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France.,Institut Mondor de Recherche Biomédicale INSERM 955, Créteil, France
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11
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Carteaux G, Parfait M, Combet M, Haudebourg AF, Tuffet S, Mekontso Dessap A. Patient-Self Inflicted Lung Injury: A Practical Review. J Clin Med 2021; 10:jcm10122738. [PMID: 34205783 PMCID: PMC8234933 DOI: 10.3390/jcm10122738] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/15/2021] [Accepted: 06/19/2021] [Indexed: 12/14/2022] Open
Abstract
Patients with severe lung injury usually have a high respiratory drive, resulting in intense inspiratory effort that may even worsen lung damage by several mechanisms gathered under the name “patient-self inflicted lung injury” (P-SILI). Even though no clinical study has yet demonstrated that a ventilatory strategy to limit the risk of P-SILI can improve the outcome, the concept of P-SILI relies on sound physiological reasoning, an accumulation of clinical observations and some consistent experimental data. In this review, we detail the main pathophysiological mechanisms by which the patient’s respiratory effort could become deleterious: excessive transpulmonary pressure resulting in over-distension; inhomogeneous distribution of transpulmonary pressure variations across the lung leading to cyclic opening/closing of nondependent regions and pendelluft phenomenon; increase in the transvascular pressure favoring the aggravation of pulmonary edema. We also describe potentially harmful patient-ventilator interactions. Finally, we discuss in a practical way how to detect in the clinical setting situations at risk for P-SILI and to what extent this recognition can help personalize the treatment strategy.
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Affiliation(s)
- Guillaume Carteaux
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
- INSERM U955, Institut Mondor de Recherche Biomédicale, F-94010 Créteil, France
- Correspondence:
| | - Mélodie Parfait
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
| | - Margot Combet
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
| | - Anne-Fleur Haudebourg
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
| | - Samuel Tuffet
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
- INSERM U955, Institut Mondor de Recherche Biomédicale, F-94010 Créteil, France
| | - Armand Mekontso Dessap
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
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12
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Cammarota G, Verdina F, De Vita N, Boniolo E, Tarquini R, Messina A, Zanoni M, Navalesi P, Vetrugno L, Bignami E, Corte FD, De Robertis E, Santangelo E, Vaschetto R. Effects of Varying Levels of Inspiratory Assistance with Pressure Support Ventilation and Neurally Adjusted Ventilatory Assist on Driving Pressure in Patients Recovering from Hypoxemic Respiratory Failure. J Clin Monit Comput 2021; 36:419-427. [PMID: 33559864 PMCID: PMC7871131 DOI: 10.1007/s10877-021-00668-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 01/28/2021] [Indexed: 12/29/2022]
Abstract
Background Driving pressure can be readily measured during assisted modes of ventilation such as pressure support ventilation (PSV) and neurally adjusted ventilatory assist (NAVA). The present prospective randomized crossover study aimed to assess the changes in driving pressure in response to variations in the level of assistance delivered by PSV vs NAVA. Methods 16 intubated adult patients, recovering from hypoxemic acute respiratory failure (ARF) and undergoing assisted ventilation, were randomly subjected to six 30-min-lasting trials. At baseline, PSV (PSV100) was set with the same regulation present at patient enrollment. The corresponding level of NAVA (NAVA100) was set to match the same inspiratory peak of airway pressure obtained in PSV100. Therefore, the level of assistance was reduced and increased by 50% in both ventilatory modes (PSV50, NAVA50; PSV150, NAVA150). At the end of each trial, driving pressure obtained in response to four short (2–3 s) end-expiratory and end-inspiratory occlusions was analyzed. Results Driving pressure at PSV50 (6.6 [6.1–7.8] cmH2O) was lower than that recorded at PSV100 (7.9 [7.2–9.1] cmH2O, P = 0.005) and PSV150 (9.9 [9.1–13.2] cmH2O, P < 0.0001). In NAVA, driving pressure at NAVA50 was reduced compared to NAVA150 (7.7 [5.1–8.1] cmH2O vs 8.3 [6.4–11.4] cmH2O, P = 0.013), whereas there were no changes between baseline and NAVA150 (8.5 [6.3–9.8] cmH2O vs 8.3 [6.4–11.4] cmH2O, P = 0.331, respectively). Driving pressure at PSV150 was higher than that observed in NAVA150 (P = 0.011). Conclusions NAVA delivers better lung-protective ventilation compared to PSV in hypoxemic ARF patients. Trial registration number and date of registration The present trial was prospectively registered at www.clinicatrials.gov (NCT03719365) on 24 October 2018
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Affiliation(s)
- Gianmaria Cammarota
- Anesthesia and General Intensive Care, "Maggiore Della Carità" University Hospital, Novara, Italy. .,Department of Medicine and Surgery, Università Degli Studi Di Perugia, Perugia, Italy.
| | - Federico Verdina
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Nello De Vita
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Ester Boniolo
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Riccardo Tarquini
- Anesthesia and General Intensive Care, "Maggiore Della Carità" University Hospital, Novara, Italy
| | - Antonio Messina
- Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Marta Zanoni
- Anesthesia and General Intensive Care, "Maggiore Della Carità" University Hospital, Novara, Italy
| | - Paolo Navalesi
- Department of Medicine, University of Padua, Padova, Italy
| | - Luigi Vetrugno
- Department of Medicine, Anesthesia and Intensive Care Clinic, Università Di Udine, Udine, Italy
| | - Elena Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Francesco Della Corte
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Edoardo De Robertis
- Department of Medicine and Surgery, Università Degli Studi Di Perugia, Perugia, Italy
| | - Erminio Santangelo
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Rosanna Vaschetto
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
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13
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Goligher EC, Jonkman AH, Dianti J, Vaporidi K, Beitler JR, Patel BK, Yoshida T, Jaber S, Dres M, Mauri T, Bellani G, Demoule A, Brochard L, Heunks L. Clinical strategies for implementing lung and diaphragm-protective ventilation: avoiding insufficient and excessive effort. Intensive Care Med 2020; 46:2314-2326. [PMID: 33140181 PMCID: PMC7605467 DOI: 10.1007/s00134-020-06288-9] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 10/08/2020] [Indexed: 12/12/2022]
Abstract
Mechanical ventilation may have adverse effects on both the lung and the diaphragm. Injury to the lung is mediated by excessive mechanical stress and strain, whereas the diaphragm develops atrophy as a consequence of low respiratory effort and injury in case of excessive effort. The lung and diaphragm-protective mechanical ventilation approach aims to protect both organs simultaneously whenever possible. This review summarizes practical strategies for achieving lung and diaphragm-protective targets at the bedside, focusing on inspiratory and expiratory ventilator settings, monitoring of inspiratory effort or respiratory drive, management of dyssynchrony, and sedation considerations. A number of potential future adjunctive strategies including extracorporeal CO2 removal, partial neuromuscular blockade, and neuromuscular stimulation are also discussed. While clinical trials to confirm the benefit of these approaches are awaited, clinicians should become familiar with assessing and managing patients’ respiratory effort, based on existing physiological principles. To protect the lung and the diaphragm, ventilation and sedation might be applied to avoid excessively weak or very strong respiratory efforts and patient-ventilator dysynchrony.
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Affiliation(s)
- Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, Division of Respirology, University Health Network, Toronto, Canada.,Toronto General Hospital Research Institute, Toronto, Canada
| | - Annemijn H Jonkman
- Department of Intensive Care, Amsterdam UMC, Location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Jose Dianti
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, Division of Respirology, University Health Network, Toronto, Canada
| | - Katerina Vaporidi
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Greece
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Bhakti K Patel
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL, USA
| | - Takeshi Yoshida
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Samir Jaber
- Critical Care and Anesthesia Department (DAR B), Hôpital Saint-Éloi, CHU de Montpellier, PhyMedExp, Université de Montpellier, Montpellier, France
| | - Martin Dres
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France.,Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France
| | - Tommaso Mauri
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giacomo Bellani
- Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB, Italy
| | - Alexandre Demoule
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France.,Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Leo Heunks
- Department of Intensive Care, Amsterdam UMC, Location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands.
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14
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Jonkman AH, Rauseo M, Carteaux G, Telias I, Sklar MC, Heunks L, Brochard LJ. Proportional modes of ventilation: technology to assist physiology. Intensive Care Med 2020; 46:2301-2313. [PMID: 32780167 PMCID: PMC7417783 DOI: 10.1007/s00134-020-06206-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/30/2020] [Indexed: 01/17/2023]
Abstract
Proportional modes of ventilation assist the patient by adapting to his/her effort, which contrasts with all other modes. The two proportional modes are referred to as neurally adjusted ventilatory assist (NAVA) and proportional assist ventilation with load-adjustable gain factors (PAV+): they deliver inspiratory assist in proportion to the patient’s effort, and hence directly respond to changes in ventilatory needs. Due to their working principles, NAVA and PAV+ have the ability to provide self-adjusted lung and diaphragm-protective ventilation. As these proportional modes differ from ‘classical’ modes such as pressure support ventilation (PSV), setting the inspiratory assist level is often puzzling for clinicians at the bedside as it is not based on usual parameters such as tidal volumes and PaCO2 targets. This paper provides an in-depth overview of the working principles of NAVA and PAV+ and the physiological differences with PSV. Understanding these differences is fundamental for applying any assisted mode at the bedside. We review different methods for setting inspiratory assist during NAVA and PAV+ , and (future) indices for monitoring of patient effort. Last, differences with automated modes are mentioned.
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Affiliation(s)
- Annemijn H Jonkman
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Room 4-08, Toronto, ON, M5B 1T8, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Michela Rauseo
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Room 4-08, Toronto, ON, M5B 1T8, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Guillaume Carteaux
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Créteil, F-94010, France.,Groupe de Recherche Clinique CARMAS, Université Paris Est-Créteil, Créteil, F-94010, France.,Institut Mondor de Recherche Biomédicale INSERM 955, Créteil, F-94010, France
| | - Irene Telias
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Room 4-08, Toronto, ON, M5B 1T8, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Michael C Sklar
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Room 4-08, Toronto, ON, M5B 1T8, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Leo Heunks
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Laurent J Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Room 4-08, Toronto, ON, M5B 1T8, Canada. .,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
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15
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Noninvasive Neurally Adjusted Ventilator Assist Ventilation in the Postoperative Period Produces Better Patient-Ventilator Synchrony but Not Comfort. Pulm Med 2020; 2020:4705042. [PMID: 32655950 PMCID: PMC7327603 DOI: 10.1155/2020/4705042] [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] [Received: 02/18/2020] [Revised: 04/26/2020] [Accepted: 05/21/2020] [Indexed: 11/18/2022] Open
Abstract
Background Noninvasive neurally adjusted ventilatory assist (NAVA) has been shown to improve patient-ventilator interaction in many settings. There is still scarce data with regard to postoperative patients indicated for noninvasive ventilation (NIV) which this study elates. The purpose of this trial was to evaluate postoperative patients for synchrony and comfort in noninvasive pressure support ventilation (NIV-PSV) vs. NIV-NAVA. Methods Twenty-two subjects received either NIV-NAVA or NIV-PSV in an object-blind, prospective, randomized, crossover fashion (observational trial). We evaluated blood gases and ventilator tracings throughout as well as comfort of ventilation at the end of each ventilation phase. Results There was an effective reduction in ventilator delays (p < 0.001) and negative pressure duration in NIV-NAVA as compared to NIV-PSV (p < 0.001). Although we used optimized settings in NIV-PSV, explaining the overall low incidence of asynchrony, NIV-NAVA led to reductions in the NeuroSync-index (p < 0.001) and all types of asynchrony except for double triggering that was significantly more frequent in NIV-NAVA vs. NIV-PSV (p = 0.02); ineffective efforts were reduced to zero by use of NIV-NAVA. In our population of previously lung-healthy subjects, we did not find differences in blood gases and patient comfort between the two modes. Conclusion In the postoperative setting, NIV-NAVA is well suitable for use and effective in reducing asynchronies as well as a surrogate for work of breathing. Although increased synchrony was not transferred into an increased comfort, there was an advantage with regard to patient-ventilator interaction. The trial was registered at the German clinical Trials Register (DRKS no.: DRKS00005408).
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16
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Lilitsis E, Stamatopoulou V, Andrianakis E, Petraki A, Antonogiannaki EM, Georgopoulos D, Vaporidi K, Kondili E. Inspiratory effort and breathing pattern change in response to varying the assist level: A physiological study. Respir Physiol Neurobiol 2020; 280:103474. [PMID: 32531441 PMCID: PMC7283104 DOI: 10.1016/j.resp.2020.103474] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/01/2020] [Accepted: 06/02/2020] [Indexed: 10/25/2022]
Abstract
AIM To describe the response of breathing pattern and inspiratory effort upon changes in assist level and to assesss if changes in respiratory rate may indicate changes in respiratory muscle effort. METHODS Prospective study of 82 patients ventilated on proportional assist ventilation (PAV+). At three levels of assist (20 %-50 %-80 %), patients' inspiratory effort and breathing pattern were evaluated using a validated prototype monitor. RESULTS Independent of the assist level, a wide range of respiratory rates (16-35br/min) was observed when patients' effort was within the accepted range. Changing the assist level resulted in paired changes in inspiratory effort and rate of the same tendency (increase or decrease) in all but four patients. Increasing the level in assist resulted in a 31 % (8-44 %) decrease in inspiratory effort and a 10 % (0-18 %) decrease in respiratory rate. The change in respiratory rate upon the change in assist correlated modestly with the change in the effort (R = 0.5). CONCLUSION Changing assist level results in changes in both respiratory rate and effort in the same direction, with change in effort being greater than that of respiratory rate. Yet, neither the magnitude of respiratory rate change nor the resulting absolute value may reliably predict the level of effort after a change in assist.
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Affiliation(s)
- Emmanouil Lilitsis
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece
| | - Vaia Stamatopoulou
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece
| | - Eleftherios Andrianakis
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece
| | - Adamantia Petraki
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece
| | - Elvira-Markela Antonogiannaki
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece
| | - Dimitrios Georgopoulos
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece
| | - Katerina Vaporidi
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece
| | - Eumorfia Kondili
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece.
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Diagnostic Accuracy of Diaphragm Ultrasound in Detecting and Characterizing Patient-Ventilator Asynchronies during Noninvasive Ventilation. Anesthesiology 2020; 132:1494-1502. [PMID: 32205549 DOI: 10.1097/aln.0000000000003239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Management of acute respiratory failure by noninvasive ventilation is often associated with asynchronies, like autotriggering or delayed cycling, incurred by leaks from the interface. These events are likely to impair patient's tolerance and to compromise noninvasive ventilation. The development of methods for easy detection and monitoring of asynchronies is therefore necessary. The authors describe two new methods to detect patient-ventilator asynchronies, based on ultrasound analysis of diaphragm excursion or thickening combined with airway pressure. The authors tested these methods in a diagnostic accuracy study. METHODS Fifteen healthy subjects were placed under noninvasive ventilation and subjected to artificially induced leaks in order to generate the main asynchronies (autotriggering or delayed cycling) at event-appropriate times of the respiratory cycle. Asynchronies were identified and characterized by conjoint assessment of ultrasound records and airway pressure waveforms; both were visualized on the ultrasound screen. The performance and accuracy of diaphragm excursion and thickening to detect each asynchrony were compared with a "control method" of flow/pressure tracings alone, and a "working standard method" combining flow, airway pressure, and diaphragm electromyography signals analyses. RESULTS Ultrasound recordings were performed for the 15 volunteers, unlike electromyography recordings which could be collected in only 9 of 15 patients (60%). Autotriggering was correctly identified by continuous recording of electromyography, excursion, thickening, and flow/pressure tracings with sensitivity of 93% (95% CI, 89-97%), 94% (95% CI, 91-98%), 91% (95% CI, 87-96%), and 79% (95% CI, 75-84%), respectively. Delayed cycling was detected by electromyography, excursion, thickening, and flow/pressure tracings with sensitivity of 84% (95% CI, 77-90%), 86% (95% CI, 80-93%), 89% (95% CI, 83-94%), and 67% (95% CI, 61-73%), respectively. CONCLUSIONS Ultrasound is a simple, bedside adjustable, clinical tool to detect the majority of patient-ventilator asynchronies associated with noninvasive ventilation leaks, provided that it is possible to visualize the airway pressure curve on the ultrasound machine screen. Ultrasound detection of autotriggering and delayed cycling is more accurate than isolated observation of pressure and flow tracings, and more feasible than electromyogram.
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Jonkman AH, de Vries HJ, Heunks LMA. Physiology of the Respiratory Drive in ICU Patients: Implications for Diagnosis and Treatment. Crit Care 2020; 24:104. [PMID: 32204710 PMCID: PMC7092542 DOI: 10.1186/s13054-020-2776-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2020. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2020. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
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Affiliation(s)
- Annemijn H Jonkman
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Heder J de Vries
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Leo M A Heunks
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands.
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands.
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Diniz-Silva F, Moriya HT, Alencar AM, Amato MBP, Carvalho CRR, Ferreira JC. Neurally adjusted ventilatory assist vs. pressure support to deliver protective mechanical ventilation in patients with acute respiratory distress syndrome: a randomized crossover trial. Ann Intensive Care 2020; 10:18. [PMID: 32040785 PMCID: PMC7010869 DOI: 10.1186/s13613-020-0638-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 02/02/2020] [Indexed: 01/06/2023] Open
Abstract
Background Protective mechanical ventilation is recommended for patients with acute respiratory distress syndrome (ARDS), but it usually requires controlled ventilation and sedation. Using neurally adjusted ventilatory assist (NAVA) or pressure support ventilation (PSV) could have additional benefits, including the use of lower sedative doses, improved patient–ventilator interaction and shortened duration of mechanical ventilation. We designed a pilot study to assess the feasibility of keeping tidal volume (VT) at protective levels with NAVA and PSV in patients with ARDS. Methods We conducted a prospective randomized crossover trial in five ICUs from a university hospital in Brazil and included patients with ARDS transitioning from controlled ventilation to partial ventilatory support. NAVA and PSV were applied in random order, for 15 min each, followed by 3 h in NAVA. Flow, peak airway pressure (Paw) and electrical activity of the diaphragm (EAdi) were captured from the ventilator, and a software (Matlab, Mathworks, USA), automatically detected inspiratory efforts and calculated respiratory rate (RR) and VT. Asynchrony events detection was based on waveform analysis. Results We randomized 20 patients, but the protocol was interrupted for five (25%) patients for whom we were unable to maintain VT below 6.5 mL/kg in PSV due to strong inspiratory efforts and for one patient for whom we could not detect EAdi signal. For the 14 patients who completed the protocol, VT was 5.8 ± 1.1 mL/kg for NAVA and 5.6 ± 1.0 mL/kg for PSV (p = 0.455) and there were no differences in RR (24 ± 7 for NAVA and 23 ± 7 for PSV, p = 0.661). Paw was greater in NAVA (21 ± 3 cmH2O) than in PSV (19 ± 3 cmH2O, p = 0.001). Most patients were under continuous sedation during the study. NAVA reduced triggering delay compared to PSV (p = 0.020) and the median asynchrony Index was 0.7% (0–2.7) in PSV and 0% (0–2.2) in NAVA (p = 0.6835). Conclusions It was feasible to keep VT in protective levels with NAVA and PSV for 75% of the patients. NAVA resulted in similar VT, RR and Paw compared to PSV. Our findings suggest that partial ventilatory assistance with NAVA and PSV is feasible as a protective ventilation strategy in selected ARDS patients under continuous sedation. Trial registration ClinicalTrials.gov (NCT01519258). Registered 26 January 2012, https://clinicaltrials.gov/ct2/show/NCT01519258
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Affiliation(s)
- Fabia Diniz-Silva
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, BR, Av. Dr. Enéas de Carvalho Aguiar, 44, 5 andar, bloco 2, sala 1, São Paulo, SP, CEP 05403900, Brazil
| | - Henrique T Moriya
- Biomedical Engineering Laboratory, Escola Politécnica da USP, Av. Prof. Luciano Gualberto, trav. 3, 158, Cidade Universitária, São Paulo, SP, CEP 05586-0600, Brazil
| | - Adriano M Alencar
- Instituto de Física, Universidade de São Paulo, Caixa Postal 66318, São Paulo, SP, CEP 05314-970, Brazil
| | - Marcelo B P Amato
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, BR, Av. Dr. Enéas de Carvalho Aguiar, 44, 5 andar, bloco 2, sala 1, São Paulo, SP, CEP 05403900, Brazil
| | - Carlos R R Carvalho
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, BR, Av. Dr. Enéas de Carvalho Aguiar, 44, 5 andar, bloco 2, sala 1, São Paulo, SP, CEP 05403900, Brazil
| | - Juliana C Ferreira
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, BR, Av. Dr. Enéas de Carvalho Aguiar, 44, 5 andar, bloco 2, sala 1, São Paulo, SP, CEP 05403900, Brazil.
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20
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Vaporidi K, Akoumianaki E, Telias I, Goligher EC, Brochard L, Georgopoulos D. Respiratory Drive in Critically Ill Patients. Pathophysiology and Clinical Implications. Am J Respir Crit Care Med 2020; 201:20-32. [DOI: 10.1164/rccm.201903-0596so] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Katerina Vaporidi
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School University of Crete, Heraklion, Greece
| | - Evangelia Akoumianaki
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School University of Crete, Heraklion, Greece
| | - Irene Telias
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Center and Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Ewan C. Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University Health Network, Toronto, Ontario, Canada; and
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Center and Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Dimitris Georgopoulos
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School University of Crete, Heraklion, Greece
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21
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Bridier A, François T, Baudin F, Emeriaud G. Neural feedback is effective in preterm infants during neurally adjusted ventilatory assist, when using clinically relevant settings. Pediatr Pulmonol 2019; 54:1878-1879. [PMID: 31420943 DOI: 10.1002/ppul.24478] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 07/31/2019] [Indexed: 11/07/2022]
Affiliation(s)
- Armelle Bridier
- Department of Pediatrics, Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, Montréal, Quebec, Canada
| | - Tine François
- Department of Pediatrics, Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, Montréal, Quebec, Canada
| | - Florent Baudin
- Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Réanimation pédiatrique, Bron, France.,Université de Lyon, APCSe Vetagro Sup UPSP 2016. A101, Marcy-l'Étoile, France
| | - Guillaume Emeriaud
- Department of Pediatrics, Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, Montréal, Quebec, Canada
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22
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Akoumianaki E, Vaporidi K, Georgopoulos D. The Injurious Effects of Elevated or Nonelevated Respiratory Rate during Mechanical Ventilation. Am J Respir Crit Care Med 2019; 199:149-157. [PMID: 30199652 DOI: 10.1164/rccm.201804-0726ci] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Respiratory rate is one of the key variables that is set and monitored during mechanical ventilation. As part of increasing efforts to optimize mechanical ventilation, it is prudent to expand understanding of the potential harmful effects of not only volume and pressures but also respiratory rate. The mechanisms by which respiratory rate may become injurious during mechanical ventilation can be distinguished in two broad categories. In the first, well-recognized category, concerning both controlled and assisted ventilation, the respiratory rate per se may promote ventilator-induced lung injury, dynamic hyperinflation, ineffective efforts, and respiratory alkalosis. It may also be misinterpreted as distress delaying the weaning process. In the second category, which concerns only assisted ventilation, the respiratory rate may induce injury in a less apparent way by remaining relatively quiescent while being challenged by chemical feedback. By responding minimally to chemical feedback, respiratory rate leaves the control of V. e almost exclusively to inspiratory effort. In such cases, when assist is high, weak inspiratory efforts promote ineffective triggering, periodic breathing, and diaphragmatic atrophy. Conversely, when assist is low, diaphragmatic efforts are intense and increase the risk for respiratory distress, asynchronies, ventilator-induced lung injury, diaphragmatic injury, and cardiovascular complications. This review thoroughly presents the multiple mechanisms by which respiratory rate may induce injury during mechanical ventilation, drawing the attention of critical care physicians to the potential injurious effects of respiratory rate insensitivity to chemical feedback during assisted ventilation.
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Affiliation(s)
- Evangelia Akoumianaki
- 1 Intensive Care Medicine Department, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Crete, Greece
| | - Katerina Vaporidi
- 1 Intensive Care Medicine Department, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Crete, Greece
| | - Dimitris Georgopoulos
- 1 Intensive Care Medicine Department, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Crete, Greece
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23
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Piquilloud L, Beloncle F, Richard JCM, Mancebo J, Mercat A, Brochard L. Information conveyed by electrical diaphragmatic activity during unstressed, stressed and assisted spontaneous breathing: a physiological study. Ann Intensive Care 2019; 9:89. [PMID: 31414251 PMCID: PMC6692797 DOI: 10.1186/s13613-019-0564-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 07/31/2019] [Indexed: 11/13/2022] Open
Abstract
Background The electrical activity of the crural diaphragm (Eadi), a surrogate of respiratory drive, can now be measured at the bedside in mechanically ventilated patients with a specific catheter. The expected range of Eadi values under stressed or assisted spontaneous breathing is unknown. This study explored Eadi values in healthy subjects during unstressed (baseline), stressed (with a resistance) and assisted spontaneous breathing. The relation between Eadi and inspiratory effort was analyzed. Methods Thirteen healthy male volunteers were included in this randomized crossover study. Eadi and esophageal pressure (Peso) were recorded during unstressed and stressed spontaneous breathing and under assisted ventilation delivered in pressure support (PS) at low and high assist levels and in neurally adjusted ventilatory assist (NAVA). Overall eight different situations were assessed in each participant (randomized order). Peak, mean and integral of Eadi, breathing pattern, esophageal pressure–time product (PTPeso) and work of breathing (WOB) were calculated offline. Results Median [interquartile range] peak Eadi at baseline was 17 [13–22] μV and was above 10 μV in 92% of the cases. Eadimax defined as Eadi measured at maximal inspiratory capacity reached 90 [63 to 99] μV. Median peak Eadi/Eadimax ratio was 16.8 [15.6–27.9]%. Compared to baseline, respiratory rate and minute ventilation were decreased during stressed non-assisted breathing, whereas peak Eadi and PTPeso were increased. During unstressed assisted breathing, peak Eadi decreased during high-level PS compared to unstressed non-assisted breathing and to NAVA (p = 0.047). During stressed breathing, peak Eadi was lower during all assisted ventilation modalities compared to stressed non-assisted breathing. During assisted ventilation, across the different conditions, peak Eadi changed significantly, whereas PTPeso and WOB/min were not significantly modified. Finally, Eadi signal was still present even when Peso signal was suppressed due to high assist levels. Conclusion Eadi analysis provides complementary information compared to respiratory pattern and to Peso monitoring, particularly in the presence of high assist levels. Trial registration The study was registered as NCT01818219 in clinicaltrial.gov. Registered 28 February 2013 Electronic supplementary material The online version of this article (10.1186/s13613-019-0564-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lise Piquilloud
- Medical Intensive Care Department, University Hospital of Angers, University of Angers, 4, Rue Larrey, 49100, Angers, France. .,Adult Intensive Care and Burn Unit, University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
| | - François Beloncle
- Medical Intensive Care Department, University Hospital of Angers, University of Angers, 4, Rue Larrey, 49100, Angers, France
| | - Jean-Christophe M Richard
- SAMU74, Emergency Department, General Hospital of Annecy, 1, Av de l'hôpital, 74370, Epagny Metz-Tessy, France.,INSERM, UMR 955, Créteil, France
| | - Jordi Mancebo
- Intensive Care Department, Sant Pau Hospital, Carrer de Sant Quinti 89, 08041, Barcelona, Spain
| | - Alain Mercat
- Medical Intensive Care Department, University Hospital of Angers, University of Angers, 4, Rue Larrey, 49100, Angers, France
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada
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24
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Chen C, Wen T, Liao W. Neurally adjusted ventilatory assist versus pressure support ventilation in patient-ventilator interaction and clinical outcomes: a meta-analysis of clinical trials. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:382. [PMID: 31555696 DOI: 10.21037/atm.2019.07.60] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background The objective of this study was to conduct a meta-analysis comparing neurally adjusted ventilatory assist (NAVA) with pressure support ventilation (PSV) in adult ventilated patients with patient-ventilator interaction and clinical outcomes. Methods The PubMed, the Web of Science, Scopus, and Medline were searched for appropriate clinical trials (CTs) comparing NAVA with PSV for the adult ventilated patients. RevMan 5.3 was performed for comparing NAVA with PSV in asynchrony index (AI), ineffective efforts, auto-triggering, double asynchrony, premature asynchrony, breathing pattern (Peak airway pressure (Pawpeek), mean airway pressure (Pawmean), tidal volume (VT, mL/kg), minute volume (MV), respiratory muscle unloading (peak electricity of diaphragm (EAdipeak), P 0.1, VT/EAdi), clinical outcomes (ICU mortality, duration of ventilation days, ICU stay time, hospital stay time). Results Our meta-analysis included 12 studies involving a total of 331 adult ventilated patients, AI was significantly lower in NAVA group [mean difference (MD) -12.82, 95% confidence interval (CI): -21.20 to -4.44, I2=88%], and using subgroup analysis, grouped by mechanical ventilation, the results showed that NAVA also had lower AI than PSV (Mechanical ventilation, MD -9.52, 95% CI: -17.85 to -1.20, I2=87%), (Non-invasive ventilation (NIV), MD -24.55, 95% CI: -35.40 to -13.70, I2=0%). NAVA was significantly lower than the PSV in auto-triggering (MD -0.28, 95% CI: -0.51 to -0.05, I2=10%), and premature triggering (MD -2.49, 95% CI: -3.77 to -1.21, I2=29%). There were no significant differences in double triggering, ineffective efforts, breathing pattern (Pawmean, Pawpeak, VT, MV), and respiratory muscle unloading (EAdipeak, P 0.1, VT/EAdi). For clinical outcomes, NAVA was significantly lower than the PSV (MD -2.82, 95% CI: -5.55 to -0.08, I2=0%) in the duration of ventilation, but two groups did not show significant differences in ICU mortality, ICU stay time, and hospital stay time. Conclusions NAVA is more beneficial in patient-ventilator interaction than PSV, and could decrease the duration of ventilation.
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Affiliation(s)
- Chongxiang Chen
- Department of Intensive Care Unit, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China.,Guangzhou Institute of Respiratory Diseases, the First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, Guangzhou 510120, China
| | - Tianmeng Wen
- School of Public Health, Sun Yat-sen University, Guangzhou 510000, China
| | - Wei Liao
- Department of Intensive Care Unit, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
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Relationship Between Diaphragmatic Electrical Activity and Esophageal Pressure Monitoring in Children. Pediatr Crit Care Med 2019; 20:e319-e325. [PMID: 31107378 DOI: 10.1097/pcc.0000000000001981] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Mechanical ventilation is an essential life support technology, but it is associated with side effects in case of over or under-assistance. The monitoring of respiratory effort may facilitate titration of the support. The gold standard for respiratory effort measurement is based on esophageal pressure monitoring, a technology not commonly available at bedside. Diaphragmatic electrical activity can be routinely monitored in clinical practice and reflects the output of the respiratory centers. We hypothesized that diaphragmatic electrical activity changes accurately reflect changes in mechanical efforts. The objectives of this study were to characterize the relationship between diaphragmatic electrical activity and esophageal pressure. DESIGN Prospective crossover study. SETTING Esophageal pressure and diaphragmatic electrical activity were simultaneously recorded using a specific nasogastric tube in three conditions: in pressure support ventilation and in neurally adjusted ventilatory support in a random order, and then after extubation. PATIENTS Children in the weaning phase of mechanical ventilation. INTERVENTIONS The maximal swing in esophageal pressure and esophageal pressure-time product, maximum diaphragmatic electrical activity, and inspiratory diaphragmatic electrical activity integral were calculated from 100 consecutive breaths. Neuroventilatory efficiency was estimated using the ratio of tidal volume/maximum diaphragmatic electrical activity. MEASUREMENTS AND MAIN RESULTS Sixteen patients, with a median age of 4 months (interquartile range, 0.5-13 mo), and weight 5.8 kg (interquartile range, 4.1-8 kg) were included. A strong linear correlation between maximum diaphragmatic electrical activity and maximal swing in esophageal pressure (r > 0.95), and inspiratory diaphragmatic electrical activity integral and esophageal pressure-time product (r > 0.71) was observed in all ventilatory conditions. This correlation was not modified by the type of ventilatory support. CONCLUSIONS On a short-term basis, diaphragmatic electrical activity changes are strongly correlated with esophageal pressure changes. In clinical practice, diaphragmatic electrical activity monitoring may help to inform on changes in respiratory efforts.
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Carteaux G, Perier F, Maraffi T, Razazi K, De Prost N, Mekontso Dessap A. Patient self-inflicted lung injury : ce que le réanimateur doit connaître. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2019-0087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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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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Vaporidi K, Psarologakis C, Proklou A, Pediaditis E, Akoumianaki E, Koutsiana E, Chytas A, Chouvarda I, Kondili E, Georgopoulos D. Driving pressure during proportional assist ventilation: an observational study. Ann Intensive Care 2019; 9:1. [PMID: 30603960 PMCID: PMC6314935 DOI: 10.1186/s13613-018-0477-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 12/21/2018] [Indexed: 01/01/2023] Open
Abstract
Background During passive mechanical ventilation, the driving pressure of the respiratory system is an important mediator of ventilator-induced lung injury. Monitoring of driving pressure during assisted ventilation, similar to controlled ventilation, could be a tool to identify patients at risk of ventilator-induced lung injury. The aim of this study was to describe driving pressure over time and to identify whether and when high driving pressure occurs in critically ill patients during assisted ventilation. Methods Sixty-two patients fulfilling criteria for assisted ventilation were prospectively studied. Patients were included when the treating physician selected proportional assist ventilation (PAV+), a mode that estimates respiratory system compliance. In these patients, continuous recordings of all ventilator parameters were obtained for up to 72 h. Driving pressure was calculated as tidal volume-to-respiratory system compliance ratio. The distribution of driving pressure and tidal volume values over time was examined, and periods of sustained high driving pressure (≥ 15 cmH2O) and of stable compliance were identified and analyzed. Results The analysis included 3200 h of ventilation, consisting of 8.8 million samples. For most (95%) of the time, driving pressure was < 15 cmH2O and tidal volume < 11 mL/kg (of ideal body weight). In most patients, high driving pressure was observed for short periods of time (median 2.5 min). Prolonged periods of high driving pressure were observed in five patients (8%). During the 661 periods of stable compliance, high driving pressure combined with a tidal volume ≥ 8 mL/kg was observed only in 11 cases (1.6%) pertaining to four patients. High driving pressure occurred almost exclusively when respiratory system compliance was low, and compliance above 30 mL/cmH2O excluded the presence of high driving pressure with 90% sensitivity and specificity. Conclusions In critically ill patients fulfilling criteria for assisted ventilation, and ventilated in PAV+ mode, sustained high driving pressure occurred in a small, yet not negligible number of patients. The presence of sustained high driving pressure was not associated with high tidal volume, but occurred almost exclusively when compliance was below 30 mL/cmH2O. Electronic supplementary material The online version of this article (10.1186/s13613-018-0477-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Katerina Vaporidi
- Department of Intensive Care Medicine, University Hospital of Heraklion, School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece
| | - Charalambos Psarologakis
- Department of Intensive Care Medicine, University Hospital of Heraklion, School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece
| | - Athanasia Proklou
- Department of Intensive Care Medicine, University Hospital of Heraklion, School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece
| | - Emmanouil Pediaditis
- Department of Intensive Care Medicine, University Hospital of Heraklion, School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece
| | - Evangelia Akoumianaki
- Department of Intensive Care Medicine, University Hospital of Heraklion, School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece
| | - Elisavet Koutsiana
- Department of Intensive Care Medicine, University Hospital of Heraklion, School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece.,Lab of Computing Medical Informatics and Biomedical Imaging Technologies, School of Medicine, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - Achilleas Chytas
- Lab of Computing Medical Informatics and Biomedical Imaging Technologies, School of Medicine, Aristotle University of Thessaloniki, Thessaloníki, Greece.,Institute of Applied Biosciences, CERTH, Thessaloniki, Greece
| | - Ioanna Chouvarda
- Lab of Computing Medical Informatics and Biomedical Imaging Technologies, School of Medicine, Aristotle University of Thessaloniki, Thessaloníki, Greece.,Institute of Applied Biosciences, CERTH, Thessaloniki, Greece
| | - Eumorfia Kondili
- Department of Intensive Care Medicine, University Hospital of Heraklion, School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece
| | - Dimitris Georgopoulos
- Department of Intensive Care Medicine, University Hospital of Heraklion, School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece.
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Kataoka J, Kuriyama A, Norisue Y, Fujitani S. Proportional modes versus pressure support ventilation: a systematic review and meta-analysis. Ann Intensive Care 2018; 8:123. [PMID: 30535648 PMCID: PMC6288104 DOI: 10.1186/s13613-018-0470-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 12/04/2018] [Indexed: 12/29/2022] Open
Abstract
Background Proportional modes (proportional assist ventilation, PAV, and neurally adjusted ventilatory assist, NAVA) could improve patient–ventilator interaction and consequently may be efficient as a weaning mode. The purpose of this systematic review is to examine whether proportional modes improved patient–ventilator interaction and whether they had an impact on the weaning success and length of mechanical ventilation, in comparison with PSV.
Methods We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials from inception through May 13, 2018. We included both parallel-group and crossover randomized studies that examined the efficacy of proportional modes in comparison with PSV in mechanically ventilated adults. The primary outcomes were (1) asynchrony index (AI), (2) weaning failure, and (3) duration of mechanical ventilation. Results We included 15 studies (four evaluated PAV, ten evaluated NAVA, and one evaluated both modes). Although the use of proportional modes was not associated with a reduction in AI (WMD − 1.43; 95% CI − 3.11 to 0.25; p = 0.096; PAV—one study, and NAVA—seven studies), the use of proportional modes was associated with a reduction in patients with AI > 10% (RR 0.15; 95% CI 0.04–0.58; p = 0.006; PAV—two studies, and NAVA—five studies), compared with PSV. There was a significant heterogeneity among studies for AI, especially with NAVA. Compared with PSV, use of proportional modes was associated with a reduction in weaning failure (RR 0.44; 95% CI 0.26–0.75; p = 0.003; PAV—three studies) and duration of mechanical ventilation (WMD − 1.78 days; 95% CI − 3.24 to − 0.32; p = 0.017; PAV—three studies, and NAVA—two studies). Reduced duration of mechanical ventilation was found with PAV but not with NAVA. Conclusion The use of proportional modes was associated with a reduction in the incidence with AI > 10%, weaning failure and duration of mechanical ventilation, compared with PSV. However, reduced weaning failure and duration of mechanical ventilation were found with only PAV. Due to a significant heterogeneity among studies and an insufficient number of studies, further investigation seems warranted to better understand the impact of proportional modes. Clinical trial registration PROSPERO registration number, CRD42017059791. Registered 20 March 2017 Electronic supplementary material The online version of this article (10.1186/s13613-018-0470-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jun Kataoka
- Department of Pulmonary and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu, 2790001, Japan.
| | - Akira Kuriyama
- Emergency and Critical Care Center, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 7108602, Japan
| | - Yasuhiro Norisue
- Department of Pulmonary and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu, 2790001, Japan
| | - Shigeki Fujitani
- Department of Emergency Medicine and Critical Care Medicine, St. Marianna University, 2-16-1 Sugao, Miyamae-ku, Kawasaki, 2168511, Japan
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Spadaro S, Karbing DS, Dalla Corte F, Mauri T, Moro F, Gioia A, Volta CA, Rees SE. An open-loop, physiological model based decision support system can reduce pressure support while acting to preserve respiratory muscle function. J Crit Care 2018; 48:407-413. [PMID: 30317049 DOI: 10.1016/j.jcrc.2018.10.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 10/04/2018] [Accepted: 10/04/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE To assess whether a clinical decision support system (CDSS) suggests PS and FIO2 maintaining appropriate breathing effort, and minimizing FIO2. MATERIALS Prospective, cross-over study in PS ventilated ICU patients. Over support (150% baseline) and under support (50% baseline) were applied by changing PS (15 patients) or PEEP (8 patients). CDSS advice was followed. Tension time index of inspiratory muscles (TTies), respiratory and metabolic variables were measured. RESULTS PS over support (median 8.0 to 12.0 cmH2O) reduced respiratory muscle activity (TTies 0.090 ± 0.028 to 0.049 ± 0.030; p < .01), and tended to increase tidal volume (VT: 8.6 ± 3.0 to 10.1 ± 2.9 ml/kg; p = .08). CDSS advice reduced PS (6.0 cmH2O, p = .005), increased TTies (0.076 ± 0.038, p < .01), and tended to reduce VT (8.9 ± 2.4 ml/kg, p = .08). PS under support (12.0 to 4.0 cmH2O) slightly increased respiratory muscle activity, (TTies to 0.120 ± 0.044; p = .007) with no significant CDSS advice. CDSS advice reduced FIO2 by 12-14% (p = .005), resulting in median SpO2 = 96% (p < .02). PEEP changes did not result in changes in physiological variables, or CDSS advice. CONCLUSION The CDSS advised on low values of PS often not prohibiting extubation, while acting to preserve respiratory muscle function and preventing passive lung inflation. CDSS advice minimized FIO2 maintaining SpO2 at safe and beneficial values.
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Affiliation(s)
- Savino Spadaro
- Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Arcispedale Sant' Anna, University of Ferrara, Ferrara, Italy
| | - Dan Stieper Karbing
- Respiratory and Critical Care Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Francesca Dalla Corte
- Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Arcispedale Sant' Anna, University of Ferrara, Ferrara, Italy
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Federico Moro
- Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Arcispedale Sant' Anna, University of Ferrara, Ferrara, Italy
| | - Antonio Gioia
- Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Arcispedale Sant' Anna, University of Ferrara, Ferrara, Italy
| | - Carlo Alberto Volta
- Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Arcispedale Sant' Anna, University of Ferrara, Ferrara, Italy
| | - Stephen Edward Rees
- Respiratory and Critical Care Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark.
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31
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de Vries H, Jonkman A, Shi ZH, Spoelstra-de Man A, Heunks L. Assessing breathing effort in mechanical ventilation: physiology and clinical implications. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:387. [PMID: 30460261 DOI: 10.21037/atm.2018.05.53] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Recent studies have shown both beneficial and detrimental effects of patient breathing effort in mechanical ventilation. Quantification of breathing effort may allow the clinician to titrate ventilator support to physiological levels of respiratory muscle activity. In this review we will describe the physiological background and methodological issues of the most frequently used methods to quantify breathing effort, including esophageal pressure measurement, the work of breathing, the pressure-time-product, electromyography and ultrasound. We will also discuss the level of breathing effort that may be considered optimal during mechanical ventilation at different stages of critical illness.
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Affiliation(s)
- Heder de Vries
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, VU University Medical Centre, Amsterdam, The Netherlands
| | - Annemijn Jonkman
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, VU University Medical Centre, Amsterdam, The Netherlands
| | - Zhong-Hua Shi
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, VU University Medical Centre, Amsterdam, The Netherlands.,Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China
| | - Angélique Spoelstra-de Man
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, VU University Medical Centre, Amsterdam, The Netherlands
| | - Leo Heunks
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, VU University Medical Centre, Amsterdam, The Netherlands
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32
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Sood SB, Mushtaq N, Brown K, Littlefield V, Barton RP. Neurally Adjusted Ventilatory Assist Is Associated with Greater Initial Extubation Success in Postoperative Congenital Heart Disease Patients when Compared to Conventional Mechanical Ventilation. J Pediatr Intensive Care 2018; 7:147-158. [PMID: 31073487 DOI: 10.1055/s-0038-1627099] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 01/08/2017] [Indexed: 01/23/2023] Open
Abstract
Extubation failure is associated with considerable morbidity and mortality in postoperative patients with congenital heart disease (CHD). The study purpose was to investigate initial extubation success utilizing neurally adjusted ventilatory assist (NAVA) compared with pressure-regulated volume controlled, synchronized intermittent mandatory ventilation with pressure support (SIMV-PRVC + PS) for ventilatory weaning in patients who required prolonged mechanical ventilation (MV). Also, total days on MV, inotropes, sedation, analgesia, and pediatric intensive care unit (PICU) length of stay (LOS) between both groups were compared. This was a non-randomized pilot study utilizing historical controls (SIMV-PRVC + PS; n = 40) compared with a prospective study population (NAVA; n = 35) in a Level I PICU and was implemented to help future trial designs. All patients ( n = 75) required prolonged MV ≥96 hours due to their complex postoperative course. Ventilator weaning initiation and management was standardized between both groups. Ninety-seven percent of the NAVA group was successfully extubated on the initial attempt, while 80% were in the SIMV-PRVC + PS group ( p = 0.0317). Patients placed on NAVA were eight times more likely to have successful initial extubation (odds ratio [OR]: 8.50, 95% confidence interval [CI]: 1.01, 71.82). The NAVA group demonstrated a shorter median duration on MV (9.0 vs. 11.0 days, p = 0.032), PICU LOS (9.0 vs. 13.5 days, p < 0.0001), and shorter median duration of days on dopamine (8.0 vs. 11.0 days, p = 0.0022), milrinone (9.0 vs. 12.0 days, p = 0.0002), midazolam (8.0 vs. 12.0 days, p < 0.0001), and fentanyl (9.0 vs. 12.5 days, p < 0.0001) compared with the SIMV-PRVC + PS group. NAVA compared with SIMV-PRVC + PS was associated with a greater initial extubation success rate. NAVA should be considered as a mechanical ventilator weaning strategy in postoperative congenital heart disease (CHD) patients and warrants further investigation.
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Affiliation(s)
- Shawn Berry Sood
- Department of Pediatrics, University of Oklahoma School of Community Medicine, Tulsa, Oklahoma, United States
| | - Nasir Mushtaq
- Department of Pediatrics, University of Oklahoma School of Community Medicine, Tulsa, Oklahoma, United States
| | - Kellie Brown
- Division of Pediatric Intensive Care, The Children's Hospital at Saint Francis, 6161 South Yale Avenue, Tulsa, Oklahoma 74136, United States
| | - Vanette Littlefield
- Division of Pediatric Intensive Care, The Children's Hospital at Saint Francis, 6161 South Yale Avenue, Tulsa, Oklahoma 74136, United States
| | - Roger Phillip Barton
- Division of Pediatric Intensive Care, The Children's Hospital at Saint Francis, 6161 South Yale Avenue, Tulsa, Oklahoma 74136, United States
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33
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Akoumianaki E, Dousse N, Lyazidi A, Lefebvre JC, Graf S, Cordioli RL, Rey N, Richard JCM, Brochard L. Can proportional ventilation modes facilitate exercise in critically ill patients? A physiological cross-over study : Pressure support versus proportional ventilation during lower limb exercise in ventilated critically ill patients. Ann Intensive Care 2017; 7:64. [PMID: 28608135 PMCID: PMC5468357 DOI: 10.1186/s13613-017-0289-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 06/03/2017] [Indexed: 12/30/2022] Open
Abstract
Background Early exercise of critically ill patients may have beneficial effects on muscle strength, mass and systemic inflammation. During pressure support ventilation (PSV), a mismatch between demand and assist could increase work of breathing and limit exercise. A better exercise tolerance is possible with a proportional mode of ventilation (Proportional Assist Ventilation, PAV+ and Neurally Adjusted Ventilatory Assist, NAVA). We examined whether, in critically ill patients, PSV and proportional ventilation have different effects on respiratory muscles unloading and work efficiency during exercise. Methods Prospective pilot randomized cross-over study performed in a medico-surgical ICU. Patients requiring mechanical ventilation >48 h were enrolled. At initiation, the patients underwent an incremental workload test on a cycloergometer to determine the maximum level capacity. The next day, 2 15-min exercise, at 60% of the maximum capacity, were performed while patients were randomly ventilated with PSV and PAV+ or NAVA. The change in oxygen consumption (ΔVO2, indirect calorimetry) and the work efficiency (ratio of ΔVO2 per mean power) were computed. Results Ten patients were examined, 6 ventilated with PSV/PAV+ and 4 with PSV/NAVA. Despite the same mean inspiratory pressure at baseline between the modes, baseline VO2 (median, IQR) was higher during proportional ventilation (301 ml/min, 270–342) compared to PSV (249 ml/min, 206–353). Exercise with PSV was associated with a significant increase in VO2 (ΔVO2, median, IQR) (77.6 ml/min, 59.9–96.5), while VO2 did not significantly change during exercise with proportional modes (46.3 ml/min, 5.7–63.7, p < 0.05). As a result, exercise with proportional modes was associated with a better work efficiency than with PSV. The ventilator modes did not affect patient’s dyspnea, limb fatigue, distance, hemodynamics and breathing pattern. Conclusions Proportional ventilation during exercise results in higher work efficiency and less increase in VO2 compared to ventilation with PSV. These preliminary findings suggest that proportional ventilation could enhance the training effect and facilitate rehabilitation. Electronic supplementary material The online version of this article (doi:10.1186/s13613-017-0289-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Nicolas Dousse
- Division of Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Aissam Lyazidi
- Institut Supérieur des Sciences de la Santé, Laboratory Rayonnement-Matiére et Instrumentation, Université Hassan 1er, Settat, Morocco
| | - Jean-Claude Lefebvre
- Department of Anesthesiology and Critical Care, Université Laval, Quebec, QC, Canada
| | - Severine Graf
- Division of Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Ricardo Luiz Cordioli
- Department of Adult Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Nathalie Rey
- Department of Anesthesia and Intensive Care Unit, Rouen University Hospital, Rouen, France
| | | | - Laurent Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
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Beloncle F, Piquilloud L, Rittayamai N, Sinderby C, Rozé H, Brochard L. A diaphragmatic electrical activity-based optimization strategy during pressure support ventilation improves synchronization but does not impact work of breathing. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:21. [PMID: 28137269 PMCID: PMC5282691 DOI: 10.1186/s13054-017-1599-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 01/04/2017] [Indexed: 12/14/2022]
Abstract
Background Poor patient-ventilator synchronization is often observed during pressure support ventilation (PSV) and has been associated with prolonged duration of mechanical ventilation and poor outcome. Diaphragmatic electrical activity (Eadi) recorded using specialized nasogastric tubes is a surrogate of respiratory brain stem output. This study aimed at testing whether adapting ventilator settings during PSV using a protocolized Eadi-based optimization strategy, or Eadi-triggered and -cycled assisted pressure ventilation (or PSVN) could (1) improve patient-ventilator interaction and (2) reduce or normalize patient respiratory effort as estimated by the work of breathing (WOB) and the pressure time product (PTP). Methods This was a prospective cross-over study. Patients with a known chronic pulmonary obstructive or restrictive disease, asynchronies or suspected intrinsic positive end-expiratory pressure (PEEP) who were ventilated using PSV were enrolled in the study. Four different ventilator settings were sequentially applied for 15 minutes (step 1: baseline PSV as set by the clinician, step 2: Eadi-optimized PSV to adjust PS level, inspiratory trigger, and cycling settings, step 3: step 2 + PEEP adjustment, step 4: PSVN). The same settings as step 3 were applied again after step 4 to rule out a potential effect of time. Breathing pattern, trigger delay (Td), inspiratory time in excess (Tiex), pressure-time product (PTP), and work of breathing (WOB) were measured at the end of each step. Results Eleven patients were enrolled in the study. Eadi-optimized PSV reduced Td without altering Tiex in comparison with baseline PSV. PSVN reduced Td and Tiex in comparison with baseline and Eadi-optimized PSV. Respiratory pattern did not change during the four steps. The improvement in patient-ventilator interaction did not lead to changes in WOB or PTP. Conclusions Eadi-optimized PSV allows improving patient ventilator interaction but does not alter patient effort in patients with mild asynchrony. Trial registration Clinicaltrials.gov identifier: NCT 02067403. Registered 7 February 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1599-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Francois Beloncle
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Research Centre and Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada.,Medical Intensive Care Unit, Hospital of Angers, University of Angers, Angers, France
| | - Lise Piquilloud
- Medical Intensive Care Unit, Hospital of Angers, University of Angers, Angers, France.,Adult Intensive Care and Burn Unit, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Nuttapol Rittayamai
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Research Centre and Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada.,Division of Respiratory Diseases and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Christer Sinderby
- Keenan Research Centre and Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada
| | - Hadrien Rozé
- CHU de Bordeaux, Service d'Anesthesie-Reanimation 2, Pessac, 33600, France
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada. .,Keenan Research Centre and Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada.
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35
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Villar J, Belda J, Blanco J, Suarez-Sipmann F, Añón JM, Pérez-Méndez L, Ferrando C, Parrilla D, Montiel R, Corpas R, González-Higueras E, Pestaña D, Martínez D, Fernández L, Soro M, García-Bello MA, Fernández RL, Kacmarek RM. Neurally adjusted ventilatory assist in patients with acute respiratory failure: study protocol for a randomized controlled trial. Trials 2016; 17:500. [PMID: 27737690 PMCID: PMC5064782 DOI: 10.1186/s13063-016-1625-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 09/25/2016] [Indexed: 12/25/2022] Open
Abstract
Background Patient-ventilator asynchrony is a common problem in mechanically ventilated patients with acute respiratory failure. It is assumed that asynchronies worsen lung function and prolong the duration of mechanical ventilation (MV). Neurally Adjusted Ventilatory Assist (NAVA) is a novel approach to MV based on neural respiratory center output that is able to trigger, cycle, and regulate the ventilatory cycle. We hypothesized that the use of NAVA compared to conventional lung-protective MV will result in a reduction of the duration of MV. It is further hypothesized that NAVA compared to conventional lung-protective MV will result in a decrease in the length of ICU and hospital stay, and mortality. Methods/design This is a prospective, multicenter, randomized controlled trial in 306 mechanically ventilated patients with acute respiratory failure from several etiologies. Only patients ventilated for less than 5 days, and who are expected to require prolonged MV for an additional 72 h or more and are able to breathe spontaneously, will be considered for enrollment. Eligible patients will be randomly allocated to two ventilatory arms: (1) conventional lung-protective MV (n = 153) and conventional lung-protective MV with NAVA (n = 153). Primary outcome is the number of ventilator-free days, defined as days alive and free from MV at day 28 after endotracheal intubation. Secondary outcomes are total length of MV, and ICU and hospital mortality. Discussion This is the first randomized clinical trial examining, on a multicenter scale, the beneficial effects of NAVA in reducing the dependency on MV of patients with acute respiratory failure. Trial registration ClinicalTrials.gov website (NCT01730794). Registered on 15 November 2012. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1625-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Monforte de Lemos 3-5, Pabellon 11, 28029, Madrid, Spain. .,Multidisciplinary Organ Dysfunction Evaluation Research Network, Research Unit, Hospital Universitario Dr. Negrín, Barranco de la Ballena s/n, 4th Floor-South Wing, 35019, Las Palmas de Gran Canaria, Spain. .,Keenan Research Center for Biomedical Science at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada.
| | - Javier Belda
- Department of Anesthesiology, Hospital Clínico Universitario de Valencia, Avda. Blasco Ibañez 17, 46010, Valencia, Spain
| | - Jesús Blanco
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Monforte de Lemos 3-5, Pabellon 11, 28029, Madrid, Spain.,Intensive Care Unit, Hospital Universitario Río Hortega, Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Fernando Suarez-Sipmann
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Monforte de Lemos 3-5, Pabellon 11, 28029, Madrid, Spain.,Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University Hospital, Akademiska Sjukhuset, Ing 40, Tr 3, SE-75185, Uppsala, Sweden
| | - José Manuel Añón
- Intensive Care Unit, Hospital Virgen de La Luz, Hermandad de Donantes de Sangre s/n, 16002, Cuenca, Spain
| | - Lina Pérez-Méndez
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Monforte de Lemos 3-5, Pabellon 11, 28029, Madrid, Spain.,Division of Clinical Epidemiology and Biostatistics, Research Unit, Hospital Universitario NS de Candelaria, Carretera General del Rosario 145, 38010, Santa Cruz de Tenerife, Spain
| | - Carlos Ferrando
- Department of Anesthesiology, Hospital Clínico Universitario de Valencia, Avda. Blasco Ibañez 17, 46010, Valencia, Spain
| | - Dácil Parrilla
- Intensive Care Unit, Hospital Universitario NS de Candelaria, Carretera General del Rosario 145, 38010, Santa Cruz de Tenerife, Spain
| | - Raquel Montiel
- Intensive Care Unit, Hospital Universitario NS de Candelaria, Carretera General del Rosario 145, 38010, Santa Cruz de Tenerife, Spain
| | - Ruth Corpas
- Intensive Care Unit, Hospital General NS del Prado, Carretera de Madrid, Km. 114, 45600, Talavera de la Reina, Toledo, Spain
| | - Elena González-Higueras
- Intensive Care Unit, Hospital Virgen de La Luz, Hermandad de Donantes de Sangre s/n, 16002, Cuenca, Spain
| | - David Pestaña
- Department of Anesthesiology, Hospital Universitario Ramón y Cajal, Carretera de Colmenar Viejo, Km. 9,100, 28034, Madrid, Spain
| | - Domingo Martínez
- Intensive Care Unit, Hospital Universitario Virgen de la Arrixaca, Carretera Madrid-Cartagena s/n, 30120, El Palmar, Murcia, Spain
| | - Lorena Fernández
- Intensive Care Unit, Hospital Universitario Río Hortega, Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Marina Soro
- Department of Anesthesiology, Hospital Clínico Universitario de Valencia, Avda. Blasco Ibañez 17, 46010, Valencia, Spain
| | - Miguel Angel García-Bello
- Division of Biostatistics, Research Unit, Hospital Universitario Dr. Negrín, Barranco de la Ballena s/n, 35019, Las Palmas de Gran Canaria, Spain
| | - Rosa Lidia Fernández
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Monforte de Lemos 3-5, Pabellon 11, 28029, Madrid, Spain.,Multidisciplinary Organ Dysfunction Evaluation Research Network, Research Unit, Hospital Universitario Dr. Negrín, Barranco de la Ballena s/n, 4th Floor-South Wing, 35019, Las Palmas de Gran Canaria, Spain
| | - Robert M Kacmarek
- Department of Respiratory Care, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.,Department of Anesthesiology, Harvard University, 55 Fruit Street Gray-Bigelow 444, Boston, MA, 02144, USA
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