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Abstract
INTRODUCTION The use of mechanical ventilation is an invaluable tool in caring for critically ill patients. Enhancing our capabilities in mechanical ventilation has been instrumental in the ability to support clinical conditions and diseases which were once associated with high mortality. Areas covered: Within this manuscript, we will look to discuss emerging approaches to improving the care of pediatric patients who require mechanical ventilation. After an extensive literature search, we will provide a brief review of the history and pathophysiology of acute respiratory distress syndrome, an assessment of several ventilator settings, a discussion on assisted ventilation, review of therapy used to rescue in severe respiratory failure, methods of monitoring the effects of mechanical ventilation, and nutrition. Expert opinion: As we have advanced in our care, we are seeing children survive illnesses that would have once claimed their lives. Given this knowledge, we must continue to advance the research in pediatric critical care to understand the means in which we can tailor the therapy to the patient in efforts to efficiently liberate them from mechanical ventilation once their illness has resolved.
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Affiliation(s)
- Duane C Williams
- a Division of Pediatric Critical Care Medicine, Department of Pediatrics , Penn State Hershey Children's Hospital , Hershey , PA , USA
| | - Ira M Cheifetz
- b Division of Pediatric Critical Care Medicine, Department of Pediatrics , Duke Children's Hospital , Durham , NC , USA
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Garofalo E, Bruni A, Pelaia C, Liparota L, Lombardo N, Longhini F, Navalesi P. Recognizing, quantifying and managing patient-ventilator asynchrony in invasive and noninvasive ventilation. Expert Rev Respir Med 2018; 12:557-567. [DOI: 10.1080/17476348.2018.1480941] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Eugenio Garofalo
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Andrea Bruni
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Corrado Pelaia
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Luisa Liparota
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Nicola Lombardo
- Otolaryngology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Federico Longhini
- Anesthesia and Intensive Care, Sant’Andrea Hospital, Vercelli, Italy
| | - Paolo Navalesi
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
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Longhini F, Pan C, Xie J, Cammarota G, Bruni A, Garofalo E, Yang Y, Navalesi P, Qiu H. New setting of neurally adjusted ventilatory assist for noninvasive ventilation by facial mask: a physiologic study. Crit Care 2017; 21:170. [PMID: 28683763 PMCID: PMC5501553 DOI: 10.1186/s13054-017-1761-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 06/19/2017] [Indexed: 11/10/2022] Open
Abstract
Background Noninvasive ventilation (NIV) is generally delivered using pneumatically-triggered and cycled-off pressure support (PSP) through a mask. Neurally adjusted ventilatory assist (NAVA) is the only ventilatory mode that uses a non-pneumatic signal, i.e., diaphragm electrical activity (EAdi), to trigger and drive ventilator assistance. A specific setting to generate neurally controlled pressure support (PSN) was recently proposed for delivering NIV by helmet. We compared PSN with PSP and NAVA during NIV using a facial mask, with respect to patient comfort, gas exchange, and patient-ventilator interaction and synchrony. Methods Three 30-minute trials of NIV were randomly delivered to 14 patients immediately after extubation to prevent post-extubation respiratory failure: (1) PSP, with an inspiratory support ≥8 cmH2O; (2) NAVA, adjusting the NAVA level to achieve a comparable peak EAdi (EAdipeak) as during PSP; and (3) PSN, setting the NAVA level at 15 cmH2O/μV with an upper airway pressure (Paw) limit to obtain the same overall Paw applied during PSP. We assessed patient comfort, peak inspiratory flow (PIF), time to reach PIF (PIFtime), EAdipeak, arterial blood gases, pressure-time product of the first 300 ms (PTP300-index) and 500 ms (PTP500-index) after initiation of patient effort, inspiratory trigger delay (DelayTR-insp), and rate of asynchrony, determined as asynchrony index (AI%). The categorical variables were compared using the McNemar test, and continuous variables by the Friedman test followed by the Wilcoxon test with Bonferroni correction for multiple comparisons (p < 0.017). Results PSN significantly improved patient comfort, compared to both PSP (p = 0.001) and NAVA (p = 0.002), without differences between the two latter (p = 0.08). PIF (p = 0.109), EAdipeak (p = 0.931) and gas exchange were similar between modes. Compared to PSP and NAVA, PSN reduced PIFtime (p < 0.001), and increased PTP300-index (p = 0.004) and PTP500-index (p = 0.001). NAVA and PSN significantly reduced DelayTR-insp, as opposed to PSP (p < 0.001). During both NAVA and PSN, AI% was <10% in all patients, while AI% was ≥10% in 7 patients (50%) with PSP (p = 0.023 compared with both NAVA and PSN). Conclusions Compared to both PSP and NAVA, PSN improved comfort and patient-ventilator interaction during NIV by facial mask. PSN also improved synchrony, as opposed to PSP only. Trial registration ClinicalTrials.gov, NCT03041402. Registered (retrospectively) on 2 February 2017.
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Affiliation(s)
- Federico Longhini
- Anesthesia and Intensive Care, Sant'Andrea Hospital, ASL VC, Vercelli, Italy
| | - Chun Pan
- Department of Critical Care Medicine, Nanjing Zhong-Da Hospital, Southeast University School of Medicine, 87 Dingjiaqiao Road, Nanjing, 210009, China
| | - Jianfeng Xie
- Department of Critical Care Medicine, Nanjing Zhong-Da Hospital, Southeast University School of Medicine, 87 Dingjiaqiao Road, Nanjing, 210009, China
| | - Gianmaria Cammarota
- Anesthesia and Intensive Care, "Maggiore della Carità" Hospital, Novara, Italy
| | - Andrea Bruni
- Intensive Care Unit, University Hospital Mater Domini, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Eugenio Garofalo
- Intensive Care Unit, University Hospital Mater Domini, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Yi Yang
- Department of Critical Care Medicine, Nanjing Zhong-Da Hospital, Southeast University School of Medicine, 87 Dingjiaqiao Road, Nanjing, 210009, China
| | - Paolo Navalesi
- Intensive Care Unit, University Hospital Mater Domini, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Haibo Qiu
- Department of Critical Care Medicine, Nanjing Zhong-Da Hospital, Southeast University School of Medicine, 87 Dingjiaqiao Road, Nanjing, 210009, China.
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Su PL, Kao PS, Lin WC, Su PF, Chen CW. Limited predictability of maximal muscular pressure using the difference between peak airway pressure and positive end-expiratory pressure during proportional assist ventilation (PAV). Crit Care 2016; 20:382. [PMID: 27888836 PMCID: PMC5124486 DOI: 10.1186/s13054-016-1554-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 10/31/2016] [Indexed: 11/20/2022] Open
Abstract
Background If the proportional assist ventilation (PAV) level is known, muscular effort can be estimated from the difference between peak airway pressure and positive end-expiratory pressure (PEEP) (ΔP) during PAV. We conjectured that deducing muscle pressure from ΔP may be an interesting method to set PAV, and tested this hypothesis using the oesophageal pressure time product calculation. Methods Eleven mechanically ventilated patients with oesophageal pressure monitoring under PAV were enrolled. Patients were randomly assigned to seven assist levels (20–80%, PAV20 means 20% PAV gain) for 15 min. Maximal muscular pressure calculated from oesophageal pressure (Pmus, oes) and from ΔP (Pmus, aw) and inspiratory pressure time product derived from oesophageal pressure (PTPoes) and from ΔP (PTPaw) were determined from the last minute of each level. Pmus, oes and PTPoes with consideration of PEEPi were expressed as Pmus, oes, PEEPi and PTPoes, PEEPi, respectively. Pressure time product was expressed as per minute (PTPoes, PTPoes, PEEPi, PTPaw) and per breath (PTPoes, br, PTPoes, PEEPi, br, PTPaw, br). Results PAV significantly reduced the breathing effort of patients with increasing PAV gain (PTPoes 214.3 ± 80.0 at PAV20 vs. 83.7 ± 49.3 cmH2O•s/min at PAV80, PTPoes, PEEPi 277.3 ± 96.4 at PAV20 vs. 121.4 ± 71.6 cmH2O•s/min at PAV80, p < 0.0001). Pmus, aw overestimates Pmus, oes for low-gain PAV and underestimates Pmus, oes for moderate-gain to high-gain PAV. An optimal Pmus, aw could be achieved in 91% of cases with PAV60. When the PAV gain was adjusted to Pmus, aw of 5–10 cmH2O, there was a 93% probability of PTPoes <224 cmH2O•s/min and 88% probability of PTPoes, PEEPi < 255 cmH2O•s/min. Conclusion Deducing maximal muscular pressure from ΔP during PAV has limited accuracy. The extrapolated pressure time product from ΔP is usually less than the pressure time product calculated from oesophageal pressure tracing. However, when the PAV gain was adjusted to Pmus, aw of 5–10 cmH2O, there was a 90% probability of PTPoes and PTPoes, PEEPi within acceptable ranges. This information should be considered when applying ΔP to set PAV under various gains.
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Affiliation(s)
- Po-Lan Su
- Section of Chest Medicine and Respiratory Care, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Pei-Shan Kao
- Section of Chest Medicine and Respiratory Care, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Graduate Institute of Clinical Medical Sciences; Department of Respiratory Care, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wei-Chieh Lin
- Medical Intensive Care Unit, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Pei-Fang Su
- Department of Statistics, National Cheng Kung University, Tainan, Taiwan
| | - Chang-Wen Chen
- Medical Intensive Care Unit, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan. .,Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan.
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Proportional assist ventilation versus conventional synchronized intermittent mandatory ventilation in chronic obstructive pulmonary disease. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2014. [DOI: 10.1016/j.ejcdt.2014.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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McMullen SM, Meade M, Rose L, Burns K, Mehta S, Doyle R, Henzler D. Partial ventilatory support modalities in acute lung injury and acute respiratory distress syndrome-a systematic review. PLoS One 2012; 7:e40190. [PMID: 22916094 PMCID: PMC3420868 DOI: 10.1371/journal.pone.0040190] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 06/02/2012] [Indexed: 01/21/2023] Open
Abstract
PURPOSE The efficacy of partial ventilatory support modes that allow spontaneous breathing in patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) is unclear. The objective of this scoping review was to assess the effects of partial ventilatory support on mortality, duration of mechanical ventilation, and both hospital and intensive care unit (ICU) lengths of stay (LOS) for patients with ALI and ARDS; the secondary objective was to describe physiologic effects on hemodynamics, respiratory system and other organ function. METHODS MEDLINE (1966-2009), Cochrane, and EmBase (1980-2009) databases were searched using common ventilator modes as keywords and reference lists from retrieved manuscripts hand searched for additional studies. Two researchers independently reviewed and graded the studies using a modified Oxford Centre for Evidence-Based Medicine grading system. Studies in adult ALI/ARDS patients were included for primary objectives and pre-clinical studies for supporting evidence. RESULTS Two randomized controlled trials (RCTs) were identified, in addition to six prospective cohort studies, one retrospective cohort study, one case control study, 41 clinical physiologic studies and 28 pre-clinical studies. No study was powered to assess mortality, one RCT showed shorter ICU length of stay, and the other demonstrated more ventilator free days. Beneficial effects of preserved spontaneous breathing were mainly physiological effects demonstrated as improvement of gas exchange, hemodynamics and non-pulmonary organ perfusion and function. CONCLUSIONS The use of partial ventilatory support modalities is often feasible in patients with ALI/ARDS, and may be associated with short-term physiological benefits without appreciable impact on clinically important outcomes.
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Affiliation(s)
- Sarah M. McMullen
- Department of Anesthesiology and Critical Care Medicine, Dalhousie University, Halifax, Canada
| | - Maureen Meade
- Departments of Medicine and Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada
| | - Louise Rose
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Karen Burns
- Interdepartmental Division of Critical Care, University of Toronto and St Michael's Hospital, and Li Ka Shing Knowledge Institute, Toronto, Canada
| | - Sangeeta Mehta
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Robert Doyle
- Department of Anesthesiology and Critical Care Medicine, Dalhousie University, Halifax, Canada
| | - Dietrich Henzler
- Department of Anesthesiology and Critical Care Medicine, Dalhousie University, Halifax, Canada
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Hussein K, Metwally M. Non invasive proportional assist ventilation in management of severe asthma exacerbation. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2012. [DOI: 10.1016/j.ejcdt.2012.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Abstract
PURPOSE OF REVIEW New developments in mechanical ventilation have focused on increasing the patient's control of the ventilator by implementing information on lung mechanics and respiratory drive. Effort-adapted modes of assisted breathing are presented and their potential advantages are discussed. RECENT FINDINGS Adaptive support ventilation, proportional assist ventilation with load adjustable gain factors and neurally adjusted ventilatory assist are ventilatory modes that follow the concept of adapting the assist to a defined target, instantaneous changes in respiratory drive or lung mechanics. Improved patient ventilator interaction, sufficient unloading of the respiratory muscles and increased comfort have been recently associated with these ventilator modalities. There are, however, scarce data with regard to outcome improvement, such as length of mechanical ventilation, ICU stay or mortality (commonly accepted targets to demonstrate clinical superiority). SUMMARY Within recent years, a major step forward in the evolution of assisted (effort-adapted) modes of mechanical ventilation was accomplished. There is growing evidence that supports the physiological concept of closed-loop effort-adapted assisted modes of mechanical ventilation. However, at present, the translation into a clear outcome benefit remains to be proven. In order to fill the knowledge gap that impedes the broader application, larger randomized controlled trials are urgently needed. However, with clearly proven drawbacks of conventional assisted modes such as pressure support ventilation, it is probably about time to leave these modes introduced decades ago behind.
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Cammarota G, Olivieri C, Costa R, Vaschetto R, Colombo D, Turucz E, Longhini F, Della Corte F, Conti G, Navalesi P. Noninvasive ventilation through a helmet in postextubation hypoxemic patients: physiologic comparison between neurally adjusted ventilatory assist and pressure support ventilation. Intensive Care Med 2011; 37:1943-50. [PMID: 22005826 DOI: 10.1007/s00134-011-2382-2] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Accepted: 09/21/2011] [Indexed: 11/30/2022]
Abstract
PURPOSE Neurally adjusted ventilatory assist (NAVA) has been shown to improve patient-ventilator interaction and reduce asynchronies in intubated patients, as opposed to pressure support ventilation (PSV). This is a short-term head-to-head physiologic comparison between PSV and NAVA in delivering noninvasive ventilation through a helmet (h-NIV), in patients with postextubation hypoxemic acute respiratory failure. METHODS Ten patients underwent three 20-min trials of h-NIV in PSV, NAVA, and PSV again. Arterial blood gases (ABGs) were assessed at the end of each trial. Diaphragm electrical activity (EAdi) and airway pressure (P (aw)) were recorded to derive neural and mechanical respiratory rate and timing, inspiratory (delay(TR-insp)) and expiratory trigger delays (delay(TR-exp)), time of synchrony between diaphragm contraction and ventilator assistance (time(synch)), and the asynchrony index (AI). RESULTS ABGs, peak EAdi, peak P (aw), respiratory rate, either neural or mechanical, neural timing, and delay(TR-exp) were not different between trials. Compared with PSV, with NAVA the mechanical expiratory time was significantly shorter, while the inspiratory time and duty cycle were greater. Time(synch) was 0.79 ± 0.35 s in NAVA versus 0.60 ± 0.30 s and 0.55 ± 0.29 s during the PSV trials (p < 0.01 for both). AI exceeded 10% during both PSV trials, while not in NAVA (p < 0.001). CONCLUSIONS Compared with PSV, NAVA improves patient-ventilator interaction and synchrony, with no difference in gas exchange, respiratory rate, and neural drive and timing.
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Affiliation(s)
- Gianmaria Cammarota
- Anesthesia and Intensive Care, Maggiore della Carità University Hospital, Novara, Italy
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Costa R, Spinazzola G, Cipriani F, Ferrone G, Festa O, Arcangeli A, Antonelli M, Proietti R, Conti G. A physiologic comparison of proportional assist ventilation with load-adjustable gain factors (PAV+) versus pressure support ventilation (PSV). Intensive Care Med 2011; 37:1494-500. [DOI: 10.1007/s00134-011-2297-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Accepted: 06/08/2011] [Indexed: 10/18/2022]
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Trabajo y patrón respiratorio con diferentes niveles de ventilación asistida proporcional. Med Intensiva 2009; 33:269-75. [DOI: 10.1016/s0210-5691(09)72194-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2008] [Accepted: 12/22/2008] [Indexed: 11/22/2022]
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Sinderby C, Beck J. Proportional Assist Ventilation and Neurally Adjusted Ventilatory Assist—Better Approaches to Patient Ventilator Synchrony? Clin Chest Med 2008; 29:329-42, vii. [DOI: 10.1016/j.ccm.2008.01.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Ventilatory Management of Obstructive Airway Disease. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50012-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Is One Fixed Level of Assist Sufficient to Mechanically Ventilate Spontaneously Breathing Patients? Intensive Care Med 2007. [DOI: 10.1007/978-0-387-49518-7_31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mirkovic T, Paver-Erzen V, Klokocovnik T, Gursahaney A, Hernandez P, Gottfried SB. Tracheal pressure regulated volume assist ventilation in acute respiratory failure. Can J Anaesth 2007; 54:420-9. [PMID: 17541070 DOI: 10.1007/bf03022027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
PURPOSE Proportional assist ventilation (PAV) uses volume assist (VAV) and flow assist ventilation (FAV) to reduce elastic and resistive effort, respectively. Proportional assist ventilation may be difficult to apply clinically, particularly due to FAV related considerations. It was hypothesized that regulating tracheal (Ptr) rather than airway opening pressure (Pao), to overcome endotracheal tube related resistive effort, during VAV would provide an effective alternative method of ventilation. We therefore compared the effects of Pao and Ptr regulated VAV on breathing pattern and inspiratory effort. METHODS In seven intubated patients, flow, volume, Pao, Ptr, esophageal and transdiaphragmatic pressure were measured during VAV (0-80% respiratory system elastance) using Pao vs Ptr to regulate ventilator applied pressure. Breathing pattern and the pressure-time integral of the inspiratory muscles (integralP(mus) . dt) and diaphragm (integralP(di) . dt) were determined. RESULTS Compared to spontaneous breathing, the respiratory rate to tidal volume ratio, or rapid shallow breathing index (RSBI), improved progressively with increasing VAV (130 +/- 64 vs 70 +/- 35, VAV 0 vs 80%; P < 0.05) while inspiratory effort fell (integralP(mus) . dt = 39.6 +/- 7.5 vs 28.5 +/- 7.2 cm H(2)O.sec.L(-1), integralP(di) . dt, = 35.4 +/- 7.8 vs 24.2 +/- 5.9 cm H(2)O.sec.L(-1), VAV 0 vs 80%; P < 0.05) due to a decrease in elastic related effort. At any given level of support, there was further reduction in RSBI, integralP(mus) . dt, and integralP(di) . dt (which averaged 23.6 +/- 2.7, 33.7 +/- 4.4, and 38.5 +/- 5.1%, respectively; P < 0.05) for Ptr compared to Pao regulated VAV due to a decrease in resistive effort. CONCLUSIONS Tracheal pressure regulated VAV can be a simple and effective method of partial ventilatory support in acute respiratory failure. Further work will be needed to determine its efficacy and potential benefit relative to PAV and other modes of ventilation in routine clinical practice.
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Affiliation(s)
- Tomislav Mirkovic
- McGill University Health Centre, Royal Victoria Hospital, 687 Pine Avenue West, Room M4.10, Montreal, Quebec H3A 1A1, Canada.
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Jolliet P, Tassaux D. Clinical review: patient-ventilator interaction in chronic obstructive pulmonary disease. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2007; 10:236. [PMID: 17096868 PMCID: PMC1794446 DOI: 10.1186/cc5073] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Mechanically ventilated patients with chronic obstructive pulmonary disease often prove challenging to the clinician due to the complex pathophysiology of the disease and the high risk of patient-ventilator asynchrony. These problems are encountered in both intubated patients and those ventilated with noninvasive ventilation. Much knowledge has been gained over the years in our understanding of the mechanisms underlying the difficult interaction between these patients and the machines used to provide them with the ventilatory support they often require for prolonged periods. This paper attempts to summarize the various key issues of patient-ventilator interaction during pressure support ventilation, the most often used partial ventilatory support mode, and to draw clinicians' attention to the need for sufficient knowledge when setting the ventilator at the bedside, given the often conflicting goals that must be met.
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Affiliation(s)
- Philippe Jolliet
- Intensive Care, University Hospital, 1211 Geneva 14, Switzerland.
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Navalesi P, Costa R, Ceriana P, Carlucci A, Prinianakis G, Antonelli M, Conti G, Nava S. Non-invasive ventilation in chronic obstructive pulmonary disease patients: helmet versus facial mask. Intensive Care Med 2006; 33:74-81. [PMID: 17039354 DOI: 10.1007/s00134-006-0391-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2006] [Accepted: 09/08/2006] [Indexed: 10/24/2022]
Abstract
RATIONALE The helmet is a new interface with the potential of increasing the success rate of non-invasive ventilation by improving tolerance. OBJECTIVES To perform a physiological comparison between the helmet and the conventional facial mask in delivering non-invasive ventilation in hypercapnic patients with chronic obstructive pulmonary disease. METHODS Prospective, controlled, randomized study with cross-over design. In 10 patients we evaluated gas exchange, inspiratory effort, patient-ventilator synchrony and patient tolerance after 30 min of non-invasive ventilation delivered either by helmet or facial mask; both trials were preceded by periods of spontaneous unassisted breathing. MEASUREMENTS Arterial blood gases, inspiratory effort, duration of diaphragm contraction and ventilator assistance, effort-to-support delays (at the beginning and at the end of inspiration), number of ineffective efforts, and patient comfort. MAIN RESULTS Non-invasive ventilation improved gas exchange (p<0.05) and inspiratory effort (p<0.01) with both interfaces. The helmet, however, was less efficient than the mask in reducing inspiratory effort (p<0.05) and worsened the patient-ventilator synchrony, as indicated by the longer delays to trigger on (p<0.05) and cycle off (p<0.05) the mechanical assistance and by the number of ineffective efforts (p<0.005). Patient comfort was no different with the two interfaces. CONCLUSIONS Helmet and facial mask were equally tolerated and both were effective in ameliorating gas exchange and decreasing inspiratory effort. The helmet, however, was less efficient in decreasing inspiratory effort and worsened the patient-ventilator interaction.
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Affiliation(s)
- Paolo Navalesi
- Pneumologia Riabilitativa e Terapia Intensiva Respiratoria, Fondazione S. Maugeri IRCCS, Via S. Maugeri 10, 27100, Pavia, Italy.
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Vitacca M. New things are not always Better: proportional assist ventilation vs. pressure support ventilation. Intensive Care Med 2003; 29:1038-40. [PMID: 12918515 DOI: 10.1007/s00134-003-1707-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Fernández-Vivas M, Caturla-Such J, González de la Rosa J, Acosta-Escribano J, Alvarez-Sánchez B, Cánovas-Robles J. Noninvasive pressure support versus proportional assist ventilation in acute respiratory failure. Intensive Care Med 2003; 29:1126-33. [PMID: 12802487 DOI: 10.1007/s00134-003-1768-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2002] [Accepted: 04/15/2003] [Indexed: 10/26/2022]
Abstract
BACKGROUND Although conventional pressure ventilation (PSV) decreases the rate of intubation in acute respiratory failure, patient-ventilator dyssynchrony is a frequent cause of failure. In proportional assist ventilation (PAV), pressure is applied by the ventilator in proportion to the patient-generated volume and flow; therefore, there is automatic synchrony between the patient's effort and the ventilatory cycle. OBJECTIVE The aim of this study was to compare the effects of PSV and PAV during noninvasive ventilation in the treatment of acute respiratory failure. DESIGN Prospective randomised study. SETTING A multidisciplinary 24-bed intensive care unit of an acute-care teaching hospital in Alicante, Spain. PATIENTS. This study included 117 consecutive adult patients with acute respiratory failure randomised to noninvasive ventilation delivered by PSV ( n = 59) or PAV ( n = 58). MEASUREMENTS AND RESULTS There were no statistically significant differences between patients assigned to each mode of ventilation with regard to baseline parameters and aetiological diagnoses of acute respiratory failure. With regard to outcome data, no significant differences were observed between PSV and PAV in the frequency of intubation (37% vs 34%), mortality rate (29% vs 28%), and mean length of stay. Subjective comfort (0-10 visual analogue scale) was rated higher and intolerance occurred less frequently (3.4% vs 15%, P = 0.03) in the PAV than in the PSV mode. CONCLUSIONS Although PAV seems more comfortable and intolerance occurred less frequently, no major differences exist in terms of physiological improvement or in terms of outcomes when comparing PSV and PAV.
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Affiliation(s)
- Miguel Fernández-Vivas
- Intensive Care Unit, Hospital General Universitario de Alicante, Maestro Alonso 109, 03010, Alicante, Spain.
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Delaere S, Roeseler J, D'hoore W, Matte P, Reynaert M, Jolliet P, Sottiaux T, Liistro G. Respiratory muscle workload in intubated, spontaneously breathing patients without COPD: pressure support vs proportional assist ventilation. Intensive Care Med 2003; 29:949-954. [PMID: 12664221 DOI: 10.1007/s00134-003-1704-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2002] [Accepted: 02/14/2003] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare the respiratory muscle workload associated with pressure support ventilation (PSV) and proportional assist ventilation (PAV) in intubated and spontaneously breathing patients without COPD. DESIGN AND SETTING Prospective study, intensive care unit university hospital. INTERVENTIONS Twenty intubated patients, during early weaning, PSV settings made by clinician in charge of the patient, and two levels of PAV, set to counterbalance 80% (PAV 80) and 50% (PAV 50) of both elastic and resistive loads, respectively. The patients were ventilated in the following order: 1) PSV; 2) PAV 50 or PAV 80; 3) PSV; 4) PAV 80 or PAV 50; 5) PSV. PSV settings were kept constant. MEASUREMENTS Arterial blood gases, breathing pattern and respiratory effort parameters at the end of each of the five steps. MAIN RESULTS PSV and PAV 80 had the same effects on work of breathing (WOB). The pressure-time product (PTP) was significantly higher during PAV 80 than during PSV (90+/-76 and 61+/-56 cmH(2)O.s.min(-1), respectively, P <0.05). Tidal volume was comparable, albeit more variable with PAV 80 than with PSV (variation coefficient, 43% vs 25%, respectively, P <0.05). PAV 50 entailed a higher respiratory rate, lower tidal volume, and higher WOB and PTP than PSV and PAV 80. PaO(2)/FiO(2) and SaO(2) were lower with PAV 50 than with PSV and PAV 80. CONCLUSION In a group of intubated spontaneously breathing non-COPD patients, PAV 80 and PSV were associated with comparable levels WOB, whereas PTP was higher during PAV 80. PAV 50 provided insufficient respiratory assistance.
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Affiliation(s)
- Stéphanie Delaere
- Intensive Care Department, Cliniques Universitaires St Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Jean Roeseler
- Intensive Care Department, Cliniques Universitaires St Luc, Université Catholique de Louvain, Brussels, Belgium
| | - William D'hoore
- Intensive Care Department, Cliniques Universitaires St Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Pascal Matte
- Intensive Care Department, Cliniques Universitaires St Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Marc Reynaert
- Intensive Care Department, Cliniques Universitaires St Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Philippe Jolliet
- Intensive Care Unit, Medical ICU Division, University Hospital, Geneva, Switzerland
| | | | - Giuseppe Liistro
- Pneumology Unit, Cliniques Universitaires St Luc (UCL), Université Catholique de Louvain, 10 Avenue Hippocrate, 1200 , Brussels, Belgium.
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22
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Navalesi P, Costa R. New modes of mechanical ventilation: proportional assist ventilation, neurally adjusted ventilatory assist, and fractal ventilation. Curr Opin Crit Care 2003; 9:51-8. [PMID: 12548030 DOI: 10.1097/00075198-200302000-00010] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Increased knowledge of the mechanisms that determine respiratory failure has led to the development of new technologies aimed at improving ventilatory treatment. Proportional assist ventilation and neurally adjusted ventilatory assist have been designed with the goal of improving patient-ventilator interaction by matching the ventilator support with the neural output of the respiratory centers. With proportional assist ventilation, the support is continuously readjusted in proportion to the predicted inspiratory effort. Neurally adjusted ventilatory assist is an experimental mode in which the assistance is delivered in proportion to the electrical activity of the diaphragm, assessed by means of an esophageal electrode. Biologically variable (or fractal) ventilation is a new, volume-targeted, controlled ventilation mode aimed at improving oxygenation; it incorporates the breath-to-breath variability that characterizes a natural breathing pattern.
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Affiliation(s)
- Paolo Navalesi
- Pneumologia e Terapia Intensiva Respiratoria, Fondazione S. Maugeri, Pavia, Italy.
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23
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Du HL, Ohtsuji M, Shigeta M, Chao DC, Sasaki K, Usuda Y, Yamada Y. Expiratory asynchrony in proportional assist ventilation. Am J Respir Crit Care Med 2002; 165:972-7. [PMID: 11934724 DOI: 10.1164/ajrccm.165.7.2103049] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
One of the proposed advantages of proportional assist ventilation (PAV) has been the automatic synchrony between the end of the patient's inspiratory effort and the ventilator cycle (i.e., expiratory synchrony). However, recent clinical studies have shown a prolonged ventilator inspiratory time or even a "runaway" phenomenon with the normal use of PAV. We hypothesize that control-system delay may account for this, because in reality there is always some degree of delays between control-system's input and output in all ventilators. Computer simulation study to date has not taken into account the potential effect of control-system delay on expiratory synchrony. We therefore created a computer model in which the parameter of control-system delay time was introduced. We found that significant expiratory asynchrony may occur with this more realistic model of PAV. The ventilator flow termination may fall behind the completion of the patient inspiration by as long as 0.33 seconds under the selected simulation conditions. The inspiratory termination delay time is in proportion to the control-system delay time, the respiratory time constant, and the assist gain settings. In conclusion, this model indicates that due to the unavoidable control-system delay in the ventilators, expiratory asynchrony may be an inherent shortcoming associated with PAV.
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Affiliation(s)
- Hong-Lin Du
- Clinical Research Department, Newport Medical Instruments Inc., Newport Beach, California 92658, USA.
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24
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Ambrosino N, Rossi A. Proportional assist ventilation (PAV): a significant advance or a futile struggle between logic and practice? Thorax 2002; 57:272-6. [PMID: 11867835 PMCID: PMC1746276 DOI: 10.1136/thorax.57.3.272] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Proportional assist ventilation is a promising addition to other more conventional modes of mechanical ventilation with the theoretical advantage of improving patient-ventilator interaction. It may also be of use as a diagnostic tool in the control of breathing in mechanically ventilated patients.
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Affiliation(s)
- N Ambrosino
- Salvatore Maugeri Foundation, IRCCS, Pulmonary Rehabilitation and Respiratory Intensive Care Unit, Scientific Institute of Gussago, Italy.
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25
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Farré R, Mancini M, Rotger M, Ferrer M, Roca J, Navajas D. Oscillatory resistance measured during noninvasive proportional assist ventilation. Am J Respir Crit Care Med 2001; 164:790-4. [PMID: 11549534 DOI: 10.1164/ajrccm.164.5.2102049] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Setting proportional assist ventilation (PAV) requires the measurement of patient resistance and elastance. To avoid patient sedation/paralysis or the use of an esophageal balloon, noninvasive PAV is indirectly set by the "runaway" method or in accordance with patient comfort. The aim of this study was to ascertain whether the forced oscillation technique (FOT) applied by the ventilator during noninvasive PAV is useful in assessing patient respiratory resistance. Nasal PAV was applied to 14 patients with severe chronic obstructive pulmonary disease. During PAV a modified ventilator applied a 5-Hz pressure oscillation to noninvasively assess FOT resistance (Rrs). Lung resistance (RL) was measured in seven of the patients by using an esophageal balloon. Moreover, measurements were also performed in five of the patients when PAV was applied through the mouth. Rrs was close to RL both during nasal (Rrs = 8.9 +/- 3.1, RL = 9.0 +/- 2.6; cm H(2)O x s/L; n = 7, p > 0.05) and mouth (Rrs = 5.6 +/- 2.1, RL = 5.8 +/- 1.4; cm H(2)O x s/L; n = 5, p > 0.05) breathing. Rrs was slightly greater than the maximum value of flow assistance applied during the setting of PAV (FAmax): 11.1 +/- 5.4 and 9.5 +/- 2.9 cm H(2)O x s/L, respectively (n = 14, p > 0.05), both variables being significantly correlated (r = 0.72, p < 0.05). FOT applied by the PAV ventilator allowed the assessment of patient resistance. These results suggest that FOT could be useful in setting PAV flow assistance and in automatically and continuously updating this setting in accordance with patient resistance.
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Affiliation(s)
- R Farré
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain.
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26
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Vitacca M, Ambrosino N, Clini E, Porta R, Rampulla C, Lanini B, Nava S. Physiological response to pressure support ventilation delivered before and after extubation in patients not capable of totally spontaneous autonomous breathing. Am J Respir Crit Care Med 2001; 164:638-41. [PMID: 11520729 DOI: 10.1164/ajrccm.164.4.2010046] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We designed a prospective, physiological study in 12 patients affected by chronic respiratory disorders. The study was aimed at assessing the diaphragm energy expenditure (PTPdi), lung resistance (RL) and elastance (EL), arterial blood gases (ABG), breathing pattern, and dyspnea measured by a visual analog scale during invasive pressure support ventilation (i-PSV) and noninvasive PSV (n-PSV). The ventilator settings were kept the same. Both i-PSV and n-PSV significantly reduced the PTPdi per minute, compared with that during a T-piece trial (204.4 +/- 93.8 cm H(2)O x s/min [i-PSV]; 197.5 +/- 119.8 [n-PSV]; 393.8 +/- 129.0 [T-piece]). Expired tidal volume (VTe) was significantly higher (p < 0.05) during n-PSV (615 +/- 166 ml) than during i-PSV (519 +/- 140 ml). The respiratory pump (PTPdi/VTe) was more effective (p < 0.05) with noninvasive ventilation (22.3 +/- 2.3 cm H(2)O x s/L for i-PSV versus 17.2 +/- 3.3 for n-PSV). RL and EL were similar with the two modes of ventilation. Overall dyspnea was significantly (p < 0.05) better during n-PSV than i-PSV, whereas ABG were similar. We have shown, in patients affected by stable chronic respiratory disorders not ready to sustain totally spontaneous breathing, that i-PSV and n-PSV are equally effective in reducing the PTPdi and in improving ABG, but that n-PSV seems to be better tolerated.
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Affiliation(s)
- M Vitacca
- Respiratory Intensive Care Unit, Fondazione S. Maugeri, Istituto Scientifico di Gussago, Gussago, Italy; and Instituto Scientifico di Pavia, Pavia, Italy
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27
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Hernandez P, Maltais F, Gursahaney A, Leblanc P, Gottfried SB. Proportional assist ventilation may improve exercise performance in severe chronic obstructive pulmonary disease. JOURNAL OF CARDIOPULMONARY REHABILITATION 2001; 21:135-42. [PMID: 11409222 DOI: 10.1097/00008483-200105000-00003] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Exercise tolerance is impaired in chronic obstructive pulmonary disease (COPD), in part because of a reduction in ventilatory capacity and excessive dyspnea experienced. The authors reasoned that proportional assist ventilation (PAV), a ventilator mode in which the level of support varies proportionately with patient effort, could be used during exercise to assist ventilation. The purpose of this study was to evaluate the efficacy of PAV to improve exercise endurance and related physiologic parameters in COPD. METHODS In 8 patients (age = 62.8 years mean, +/- 6.9 standard deviation) with severe COPD (forced expiratory volume in 1 second = 0.70 +/- 0.21 L) flow, volume, dyspnea, leg fatigue, arterial blood gases, and gas exchange were measured during constant workrate exercise (37 +/- 18 watts; i.e., 80% previously determined maximum oxygen consumption). Crossover exercise trials were performed in random order: while spontaneously breathing through the experimental circuit without assistance (control trial) and with PAV (using 9.8 +/- 2.1 cm H2O/L and 3.3 +/- 1.0 cm H2O/L/sec of volume assist and flow assist, respectively). RESULTS The application of PAV during exercise was well tolerated by each subject. Compared with the control measurement at equivalent time during exercise, PAV improved breathing pattern and arterial blood gases while dyspnea was reduced. Consequently, there was a significant increase in exercise duration with PAV (323 +/- 245 seconds during the control trial compared with 507 +/- 334 seconds with PAV, P = 0.02). CONCLUSIONS Proportional assist ventilation can improve performance during constant workrate exercise in severe COPD.
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Affiliation(s)
- P Hernandez
- Divisions of Respiratory and Critical Care Medicine, McGill University Health Centre and Meakins-Christie Laboratories, McGill University, Montreal, Canada
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28
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Mols G, Vetter T, Haberthür C, Geiger K, Guttmann J. Breathing pattern and perception at different levels of volume assist and pressure support in volunteers. Crit Care Med 2001; 29:982-8. [PMID: 11378608 DOI: 10.1097/00003246-200105000-00018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Volume assist (VA) amplifies the breathing effort whereas pressure support ventilation (PSV) provides a fixed, effort-independent ventilatory support. According to the concept of VA, its level should compensate for the pathologically increased (additional) elastance (Eadd). However, it is unclear whether breathing subjects prefer an exact compensation of Eadd and whether they are able to adjust the support level by themselves. DESIGN Prospective, interventional study. SETTING Laboratory. SUBJECTS Twelve healthy volunteers, nine females, three males, aged 21-33 yrs. INTERVENTIONS Increased Eadd was generated by banding of the thorax and abdomen. Volunteers breathed via a mouthpiece with VA or PSV using a positive end-expiratory pressure of 5 cm H2O (0.5 kPa). The study was subdivided into two parts. In part I, volunteers were instructed to adjust the level of VA and PSV themselves starting from three different, randomly applied levels in each mode (2, 8, 14 cm H2O or cm H2O/L; 0.2, 0.8, 1.4 kPa[/L]). In part II, 20 levels of VA and PSV (1-20 cm H2O or cm H2O/L, 0.1-2 kPa[/L]) were randomly selected by an investigator and estimated by the volunteers using a visual analog scale. Additionally, the breathing pattern was characterized. MEASUREMENTS AND MAIN RESULTS Eadd (7.1 +/- 1.5 cm H2O/L [0.7 +/- 0.2 kPa/L], mean +/- sd) corresponded almost exactly to the "self-adjusted" VA level of part I (7.0 +/- 3.3 cm H2O/L [0.7 +/- 0.3 kPa/L]) and to the adequate level of part II (8-9 cm H2O/L [0.8-0.9 kPa/L]). The accordant PSV levels were 5.7 +/- 2.6 cm H2O (0.6 +/- 0.3 kPa) and 6-7 cm H2O (0.6-0.7 kPa). The breathing pattern was less influenced by changes of the support level with VA compared with PSV, which may explain in part the greater comfort of VA. CONCLUSIONS We confirmed the theoretical assumption that VA should be adapted to Eadd. Furthermore, we demonstrated that conscious subjects are able to adjust the level of VA and PSV themselves.
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Affiliation(s)
- G Mols
- Department of Anesthesiology and Critical Care Medicine, University of Freiburg, Freiburg, Germany
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29
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Appendini L, Confalonieri M, Rossi A. Clinical relevance of monitoring respiratory mechanics in the ventilator-supported patient: an update (1995–2000). Curr Opin Crit Care 2001; 7:41-8. [PMID: 11373510 DOI: 10.1097/00075198-200102000-00007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The introduction of mechanical ventilation in the intensive care unit environment had the merit of putting a potent life-saving tool in the physicians' hands in a number of situations; however, like most sophisticated technologies, it can cause severe side effects and eventually increase mortality if improperly applied. Assessment of respiratory mechanics serves as an aid in understanding the patient-ventilator interactions with the aim to obtain a better performance of the existing ventilator modalities. It has also provided a better understanding of patients' pathophysiology. Thanks to it, new ventilatory strategies and modalities have been developed. Finally, on-line monitoring of respiratory mechanics parameters is going to be more than a future perspective.
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Affiliation(s)
- L Appendini
- Pulmonary Division, Ospedali Riuniti di Bergamo, Bergamo, Italy
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30
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Vitacca M, Clini E, Pagani M, Bianchi L, Rossi A, Ambrosino N. Physiologic effects of early administered mask proportional assist ventilation in patients with chronic obstructive pulmonary disease and acute respiratory failure. Crit Care Med 2000; 28:1791-7. [PMID: 10890621 DOI: 10.1097/00003246-200006000-00016] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the physiologic short-term effects of noninvasive proportional assist ventilation (PAV) in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD). DESIGN Prospective, physiologic study. SETTING Respiratory intermediate intensive care unit. PATIENTS Seven patients with acute respiratory failure requiring noninvasive mechanical ventilation because of exacerbation of COPD. INTERVENTIONS PAV was administered by nasal mask as first ventilatory intervention. The setting of PAV involved a procedure to adjust volume assist and flow assist to levels corresponding to patient comfort. Volume assist was also set by means of the "run-away" procedure. Continuous positive airway pressure (CPAP) amounting to 2 cm H2O was always set by the ventilator. This setting of assistance (PAV) was applied for 45 mins. Thereafter, CPAP was increased to 5 cm H2O (PAV + CPAP-5) without any change in the PAV setting and was administered for 20 mins. Oxygen was delivered through a port of the mask in the attempt to maintain a target SaO2 >90%. MEASUREMENTS AND MAIN RESULTS Arterial blood gases, breathing pattern, and inspiratory effort were measured during unsupported breathing and at the end of PAV, and breathing pattern and inspiratory effort were measured after 20 mins of PAV + CPAP-5. PAV determined a significant increase in tidal volume and minute ventilation (+64% and +25% on average, respectively) with unchanged breathing frequency and a significant improvement in arterial blood gases (PaO2 with the same oxygen supply, from 65 +/- 15 torr to 97 +/- 36 torr; PaCO2, from 80 +/- 11 torr to 76 +/- 13 torr; pH, from 7.30 +/- 0.02 to 7.32 +/- 0.03). The pressure-time product calculated over a period of 1 min (from 318 +/- 87 to 205 +/- 145 cm H2O x sec x min(-1)) was significantly reduced. PAV + CPAP-5 resulted in a further although not significant decrease in the pressure-time product calculated over a period of 1 min (to 183 +/- 110 cm H2O x sec x min(-1)), without additional changes in the breathing pattern. CONCLUSIONS Noninvasive PAV is able to improve arterial blood gases while unloading inspiratory muscles in patients with acute exacerbation of COPD.
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Affiliation(s)
- M Vitacca
- Salvatore Maugeri Foundation IRCCS, Lung Function Unit, Medical Centre of Gussago, Italy
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Giannouli E, Webster K, Roberts D, Younes M. Response of ventilator-dependent patients to different levels of pressure support and proportional assist. Am J Respir Crit Care Med 1999; 159:1716-25. [PMID: 10351909 DOI: 10.1164/ajrccm.159.6.9704025] [Citation(s) in RCA: 136] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The ventilator's response to the patient's effort is quite different in proportional assist ventilation (PAV) and pressure support ventilation (PSV). We wished to determine whether this results in different ventilatory and breathing pattern responses to alterations in level of support and, if so, whether there are any gas exchange consequences. Fourteen patients were studied. Average elastance (E) was 22.8 (range, 14 -36) cm H2O/L and average resistance (R) was 15. 7 (range, 9-21) cm H2O/L/s. The highest PSV support (PSVmax) was that associated with a tidal volume (VT) of 10 ml/kg (20.4 +/- 3.2 cm H2O), and the highest level of PAV assist (PAVmax) was 78 +/- 7% of E and 76 +/- 7% of R. Level of assist was decreased in steps to the lowest tolerable level (PSVmin, PAVmin). Minute ventilation, VT, ventilator rate (RRvent), and arterial gas tensions were measured at each level. We also determined the patient's respiratory rate (RRpat) by adding the number of ineffective efforts (DeltaRR) to RRvent. There was no difference between PSVmin and PAVmin in any of the variables. At PSVmax, VT was significantly higher (0.90 +/- 0.30 versus 0.51 +/- 0.16 L) and RRvent was significantly lower (13.2 +/- 3.9 versus 27.6 +/- 10.5 min-1) than at PAVmax. The difference in RRvent was largely related to a progressive increase in ineffective efforts on PSV as level increased (DeltaRR 12.1 +/- 10.1 vs 1.4 +/- 2.1 with PAVmax); there was no significant difference in RRpat. The differences in breathing pattern had no consequence on arterial blood gas tensions. We conclude that substantial differences in breathing pattern may occur between PSV and PAV and that these are largely artifactual and related to different patient-ventilator interactions.
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Affiliation(s)
- E Giannouli
- Sections of Respiratory and Critical Care Medicine, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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Appendini L, Purro A, Gudjonsdottir M, Baderna P, Patessio A, Zanaboni S, Donner CF, Rossi A. Physiologic response of ventilator-dependent patients with chronic obstructive pulmonary disease to proportional assist ventilation and continuous positive airway pressure. Am J Respir Crit Care Med 1999; 159:1510-7. [PMID: 10228119 DOI: 10.1164/ajrccm.159.5.9804130] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
To investigate the physiologic effects of proportional assist ventilation (PAV) in difficult-to-wean, mechanically ventilated patients with advanced COPD, we measured in eight ICU patients the breathing pattern, neuromuscular drive (P0.1), lung mechanics, and inspiratory muscle effort (PTPdi and PTPpl) during both spontaneous breathing (SB) and ventilatory support with PAV, CPAP, and CPAP + PAV (in random sequence). PAV (volume assist [VA] and flow assist [FA]) was set as follows: dynamic lung elastance and inspiratory pulmonary resistance were measured during SB; then VA and FA were set to counterbalance the elastic and resistive loads exceeding the normal values, respectively, the inspiratory muscles bearing a normal elastic and resistive workload. CPAP was set close to dynamic intrinsic PEEP (8.3 +/- 3.4 cm H2O). We found significant reductions in P0.1 and PTPdi during both CPAP (-45 and -37%, respectively) and PAV (-50 and -48%, respectively). However, only the combination of PAV and CPAP brought P0.1 (1.69 +/- 0.97 cm H2O) and PTPdi (100 +/- 68 cm H2O. s) within normal values, and ameliorated the breathing pattern compared with SB (tidal volume: 0.69 +/- 0.33 versus 0.33 +/- 0.14 L; breathing frequency, 14.6 +/- 4.6 versus 21.0 +/- 6.5 breaths/min, respectively), without generating ineffective inspiratory efforts. We conclude that in difficult-to-wean COPD patients, (1) PAV improves ventilation and reduces both P0.1 and inspiratory muscle effort; (2) the combination of PAV and CPAP can unload the inspiratory muscles to values close to those found in normal subjects.
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Affiliation(s)
- L Appendini
- Salvatore Maugeri Foundation, IRCCS, Rehabilitation Institute of Veruno, Division of Pulmonary Disease, Veruno (No), Italy.
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Ventilatory support. Acta Anaesthesiol Scand 1997. [DOI: 10.1111/j.1399-6576.1997.tb04896.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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