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Collignon C, Khirani S, Griffon L, Renolleau S, Fauroux B, Vedrenne-Cloquet M. Impact of patient-ventilator asynchronies on the work of breathing of children under mechanical ventilation: A pilot study. Pediatr Pulmonol 2024. [PMID: 38934737 DOI: 10.1002/ppul.27157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 06/20/2024] [Indexed: 06/28/2024]
Affiliation(s)
- Charlotte Collignon
- Pediatric Noninvasive Ventilation and Sleep Unit, AP-HP University Hospital Necker-Enfants malades, Paris, France
- EA 7330 VIFASOM, Université de Paris, Paris, France
- Pediatric Intensive Care Unit, AP-HP University Hospital Necker-Enfants malades, Paris, France
- University of Paris cité, Paris, France
| | - Sonia Khirani
- Pediatric Noninvasive Ventilation and Sleep Unit, AP-HP University Hospital Necker-Enfants malades, Paris, France
- EA 7330 VIFASOM, Université de Paris, Paris, France
- ASV Santé, Gennevilliers, France
| | - Lucie Griffon
- Pediatric Noninvasive Ventilation and Sleep Unit, AP-HP University Hospital Necker-Enfants malades, Paris, France
- EA 7330 VIFASOM, Université de Paris, Paris, France
| | - Sylvain Renolleau
- Pediatric Intensive Care Unit, AP-HP University Hospital Necker-Enfants malades, Paris, France
- University of Paris cité, Paris, France
| | - Brigitte Fauroux
- Pediatric Noninvasive Ventilation and Sleep Unit, AP-HP University Hospital Necker-Enfants malades, Paris, France
- EA 7330 VIFASOM, Université de Paris, Paris, France
- University of Paris cité, Paris, France
| | - Meryl Vedrenne-Cloquet
- Pediatric Noninvasive Ventilation and Sleep Unit, AP-HP University Hospital Necker-Enfants malades, Paris, France
- University of Paris cité, Paris, France
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Blokpoel RGT, Brandsema RBR, Koopman AA, van Dijk J, Kneyber MCJ. Respiratory entrainment related reverse triggering in mechanically ventilated children. Respir Res 2024; 25:142. [PMID: 38528524 DOI: 10.1186/s12931-024-02749-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 02/25/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND The underlying pathophysiological pathways how reverse triggering is being caused are not fully understood. Respiratory entrainment may be one of these mechanisms, but both terms are used interchangeably. We sought to characterize reverse triggering and the relationship with respiratory entrainment among mechanically ventilated children with and without acute lung injury. METHODS We performed a secondary phyiology analysis of two previously published data sets of invasively mechanically ventilated children < 18 years with and without lung injury mechanically ventilated in a continuous or intermittent mandatory ventilation mode. Ventilator waveforms, electrical activity of the diaphragm measured with surface electromyography and oesophageal tracings were analyzed for entrained and non-entrained reverse triggered breaths. RESULTS In total 102 measurements (3110 min) from 67 patients (median age 4.9 [1.8 ; 19,1] months) were analyzed. Entrained RT was identified in 12 (12%) and non-entrained RT in 39 (38%) recordings. Breathing variability for entrained RT breaths was lower compared to non-entrained RT breaths. We did not observe breath stacking during entrained RT. Double triggering often occurred during non-entrained RT and led to an increased tidal volume. Patients with respiratory entrainment related RT had a shorter duration of MV and length of PICU stay. CONCLUSIONS Reverse triggering is not one entity but a clinical spectrum with different mechanisms and consequences. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Robert G T Blokpoel
- Department of Paediatrics, Division of Paediatric Intensive Care, Beatrix Children's Hospital, University Medical Center Groningen, P.O. Box 30.001 9700 RB, Groningen, CA 62, the Netherlands.
| | - Ruben B R Brandsema
- Department of Paediatrics, Division of Paediatric Intensive Care, Beatrix Children's Hospital, University Medical Center Groningen, P.O. Box 30.001 9700 RB, Groningen, CA 62, the Netherlands
| | - Alette A Koopman
- Department of Paediatrics, Division of Paediatric Intensive Care, Beatrix Children's Hospital, University Medical Center Groningen, P.O. Box 30.001 9700 RB, Groningen, CA 62, the Netherlands
| | - Jefta van Dijk
- Department of Paediatrics, Division of Paediatric Intensive Care, Beatrix Children's Hospital, University Medical Center Groningen, P.O. Box 30.001 9700 RB, Groningen, CA 62, the Netherlands
| | - Martin C J Kneyber
- Department of Paediatrics, Division of Paediatric Intensive Care, Beatrix Children's Hospital, University Medical Center Groningen, P.O. Box 30.001 9700 RB, Groningen, CA 62, the Netherlands
- Critical Care, Anesthesia, Peri-operative medicine & Emergency Medicine (CAPE), University of Groningen, Groningen, the Netherlands
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Vedrenne-Cloquet M, Khirani S, Griffon L, Collignon C, Renolleau S, Fauroux B. Respiratory effort during noninvasive positive pressure ventilation and continuous positive airway pressure in severe acute viral bronchiolitis. Pediatr Pulmonol 2023. [PMID: 37097049 DOI: 10.1002/ppul.26424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 03/22/2023] [Accepted: 03/31/2023] [Indexed: 04/26/2023]
Abstract
OBJECTIVES To assess if noninvasive positive pressure ventilation (NIPPV) is associated with a greater reduction in respiratory effort as compared to continuous positive airway pressure (CPAP) during severe acute bronchiolitis, with both supports set either clinically or physiologically. METHODS Twenty infants (median [IQR] age 1.2 [0.9; 3.2] months) treated <24 h with noninvasive respiratory support (CPAP Clin, set at 7 cmH2 O, or NIPPV Clin) for bronchiolitis were included in a prospective single-center crossover study. Esogastric pressures were measured first with the baseline support, then with the other support. For each support, recordings were performed with the clinical setting and a physiological setting (CPAP Phys and NIPPV Phys), aiming at normalising respiratory effort. Patients were then treated with the optimal support. The primary outcome was the greatest reduction in esophageal pressure-time product (PTPES /min). Other outcomes included improvement of the other components of the respiratory effort. RESULTS NIPPV Clin and Phys were associated with a lower PTPES /min (164 [105; 202] and 106 [78; 161] cmH2 O s/min, respectively) than CPAP Clin (178 [145; 236] cmH2 O s/min; p = 0.01 and 2 × 10-4 , respectively). NIPPV Clin and Phys were also associated with a significant reduction of all other markers of respiratory effort as compared to CPAP Clin. PTPES /min with NIPPV (Clin or Phys) was not different from PTPES /min with CPAP Phys. There was no significant difference between physiological and clinical settings. CONCLUSION NIPPV is associated with a significant reduction in respiratory effort as compared to CPAP set at +7 cmH2 O in infants with severe acute bronchiolitis. CPAP Phys performs as well as NIPPV Clin.
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Affiliation(s)
- Meryl Vedrenne-Cloquet
- Pediatric Noninvasive Ventilation and Sleep Unit, AP-HP, Hôpital Necker Enfants-Malades, Paris, France
- Université de Paris, EA, 7330 VIFASOM, Paris, France
- Pediatric Intensive Care Unit, AP-HP, CHU Necker-Enfants Malades, Paris, France
| | - Sonia Khirani
- Pediatric Noninvasive Ventilation and Sleep Unit, AP-HP, Hôpital Necker Enfants-Malades, Paris, France
- Université de Paris, EA, 7330 VIFASOM, Paris, France
- ASV Santé, Gennevilliers, France
| | - Lucie Griffon
- Pediatric Noninvasive Ventilation and Sleep Unit, AP-HP, Hôpital Necker Enfants-Malades, Paris, France
- Université de Paris, EA, 7330 VIFASOM, Paris, France
| | - Charlotte Collignon
- Pediatric Intensive Care Unit, AP-HP, CHU Necker-Enfants Malades, Paris, France
| | - Sylvain Renolleau
- Université de Paris, EA, 7330 VIFASOM, Paris, France
- Pediatric Intensive Care Unit, AP-HP, CHU Necker-Enfants Malades, Paris, France
| | - Brigitte Fauroux
- Pediatric Noninvasive Ventilation and Sleep Unit, AP-HP, Hôpital Necker Enfants-Malades, Paris, France
- Université de Paris, EA, 7330 VIFASOM, Paris, France
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Vedrenne-Cloquet M, Khirani S, Khemani R, Lesage F, Oualha M, Renolleau S, Chiumello D, Demoule A, Fauroux B. Pleural and transpulmonary pressures to tailor protective ventilation in children. Thorax 2023; 78:97-105. [PMID: 35803726 DOI: 10.1136/thorax-2021-218538] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 06/12/2022] [Indexed: 02/07/2023]
Abstract
This review aims to: (1) describe the rationale of pleural (PPL) and transpulmonary (PL) pressure measurements in children during mechanical ventilation (MV); (2) discuss its usefulness and limitations as a guide for protective MV; (3) propose future directions for paediatric research. We conducted a scoping review on PL in critically ill children using PubMed and Embase search engines. We included peer-reviewed studies using oesophageal (PES) and PL measurements in the paediatric intensive care unit (PICU) published until September 2021, and excluded studies in neonates and patients treated with non-invasive ventilation. PL corresponds to the difference between airway pressure and PPL Oesophageal manometry allows measurement of PES, a good surrogate of PPL, to estimate PL directly at the bedside. Lung stress is the PL, while strain corresponds to the lung deformation induced by the changing volume during insufflation. Lung stress and strain are the main determinants of MV-related injuries with PL and PPL being key components. PL-targeted therapies allow tailoring of MV: (1) Positive end-expiratory pressure (PEEP) titration based on end-expiratory PL (direct measurement) may be used to avoid lung collapse in the lung surrounding the oesophagus. The clinical benefit of such strategy has not been demonstrated yet. This approach should consider the degree of recruitable lung, and may be limited to patients in which PEEP is set to achieve an end-expiratory PL value close to zero; (2) Protective ventilation based on end-inspiratory PL (derived from the ratio of lung and respiratory system elastances), might be used to limit overdistention and volutrauma by targeting lung stress values < 20-25 cmH2O; (3) PPL may be set to target a physiological respiratory effort in order to avoid both self-induced lung injury and ventilator-induced diaphragm dysfunction; (4) PPL or PL measurements may contribute to a better understanding of cardiopulmonary interactions. The growing cardiorespiratory system makes children theoretically more susceptible to atelectrauma, myotrauma and right ventricle failure. In children with acute respiratory distress, PPL and PL measurements may help to characterise how changes in PEEP affect PPL and potentially haemodynamics. In the PICU, PPL measurement to estimate respiratory effort is useful during weaning and ventilator liberation. Finally, the use of PPL tracings may improve the detection of patient ventilator asynchronies, which are frequent in children. Despite these numerous theoritcal benefits in children, PES measurement is rarely performed in routine paediatric practice. While the lack of robust clincal data partially explains this observation, important limitations of the existing methods to estimate PPL in children, such as their invasiveness and technical limitations, associated with the lack of reference values for lung and chest wall elastances may also play a role. PPL and PL monitoring have numerous potential clinical applications in the PICU to tailor protective MV, but its usefulness is counterbalanced by technical limitations. Paediatric evidence seems currently too weak to consider oesophageal manometry as a routine respiratory monitoring. The development and validation of a noninvasive estimation of PL and multimodal respiratory monitoring may be worth to be evaluated in the future.
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Affiliation(s)
- Meryl Vedrenne-Cloquet
- Pediatric intensive care unit, Necker-Enfants Malades Hospitals, Paris, France .,Université de Paris Cité, VIFASOM, Paris, France.,Pediatric Non Invasive Ventilation Unit, Necker-Enfants Malades Hospitals, Paris, France
| | - Sonia Khirani
- Pediatric Non Invasive Ventilation Unit, Necker-Enfants Malades Hospitals, Paris, France.,ASV Santé, Genevilliers, France
| | - Robinder Khemani
- Children's Hospital Los Angeles, University of Southern California, Los Angeles, California, USA
| | - Fabrice Lesage
- Pediatric intensive care unit, Necker-Enfants Malades Hospitals, Paris, France
| | - Mehdi Oualha
- Pediatric intensive care unit, Necker-Enfants Malades Hospitals, Paris, France
| | - Sylvain Renolleau
- Pediatric intensive care unit, Necker-Enfants Malades Hospitals, Paris, France
| | - Davide Chiumello
- Dipartimento di Anestesia, Rianimazione e Terapia del Dolore, Fondazione, IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Alexandre Demoule
- Service de Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France.,UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, Sorbonne Université, INSERM, Paris, France
| | - Brigitte Fauroux
- Université de Paris Cité, VIFASOM, Paris, France.,Pediatric Non Invasive Ventilation Unit, Necker-Enfants Malades Hospitals, Paris, France
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Nickel AJ, Panitch HB, McDonough JM, Chotzoglou E, Allen JL. Pediatric Simulation of Intrinsic PEEP and Patient-Ventilator Trigger Asynchrony During Mechanical Ventilation. Respir Care 2022; 67:1405-1412. [PMID: 36127127 PMCID: PMC9993968 DOI: 10.4187/respcare.09484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Intrinsic PEEP during mechanical ventilation occurs when there is insufficient time for expiration to functional residual capacity before the next inspiration, resulting in air trapping. Increased expiratory resistance (RE), too rapid of a patient or ventilator breathing rate, or a longer inspiratory to expiratory time ratio (TI/TE) can all be causes of intrinsic PEEP. Intrinsic PEEP can result in increased work of breathing and patient-ventilator asynchrony (PVA) during patient-triggered breaths. We hypothesized that the difference between intrinsic PEEP and ventilator PEEP acts as an inspiratory load resulting in trigger asynchrony that needs to be overcome by increased respiratory muscle pressure (Pmus). METHODS Using a Servo lung model (ASL 5000) and LTV 1200 ventilator in pressure control mode, we developed a passive model demonstrating how elevated RE increases intrinsic PEEP above ventilator PEEP. We also developed an active model investigating the effects of RE and intrinsic PEEP on trigger asynchrony (expressed as percentage of patient-initiated breaths that failed to trigger). We then studied if trigger asynchrony could be reduced by increased Pmus. RESULTS Intrinsic PEEP increased significantly with increasing RE (r = 0.97, P = .006). Multivariate logistic regression analysis showed that both RE and negative Pmus levels affect trigger asynchrony (P < .001). CONCLUSIONS A passive lung model describes the development of increasing intrinsic PEEP with increasing RE at a given ventilator breathing rate. An active lung model shows how this can lead to trigger asynchrony since the Pmus needed to trigger a breath is greater with increased RE, as the inspiratory muscles must overcome intrinsic PEEP. This model will lend itself to the study of intrinsic PEEP engendered by a higher ventilator breathing rate, as well as higher TI/TE, and will be useful in ventilator simulation scenarios of PVA. The model also suggests that increasing ventilator PEEP to match intrinsic PEEP can improve trigger asynchrony through a reduction in RE.
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Affiliation(s)
- Amanda J Nickel
- Department of Respiratory Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Howard B Panitch
- Division of Pulmonary Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Joseph M McDonough
- Department of Respiratory Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Etze Chotzoglou
- Division of Pulmonary Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Julian L Allen
- Division of Pulmonary Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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Neurally-Adjusted Ventilatory Assist (NAVA) versus Pneumatically Synchronized Ventilation Modes in Children Admitted to PICU. J Clin Med 2021; 10:jcm10153393. [PMID: 34362173 PMCID: PMC8347771 DOI: 10.3390/jcm10153393] [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: 06/30/2021] [Revised: 07/27/2021] [Accepted: 07/29/2021] [Indexed: 12/02/2022] Open
Abstract
Traditionally, invasively ventilated children in the paediatric intensive care unit (PICU) are weaned using pneumatically-triggered ventilation modes with a fixed level of assist. The best weaning mode is currently not known. Neurally adjusted ventilatory assist (NAVA), a newer weaning mode, uses the electrical activity of the diaphragm (Edi) to synchronise ventilator support proportionally to the patient’s respiratory drive. We aimed to perform a systematic literature review to assess the effect of NAVA on clinical outcomes in invasively ventilated children with non-neonatal lung disease. Three studies (n = 285) were included for analysis. One randomised controlled trial (RCT) of all comers showed a significant reduction in PICU length of stay and sedative use. A cohort study of acute respiratory distress syndrome (ARDS) patients (n = 30) showed a significantly shorter duration of ventilation and improved sedation with the use of NAVA. A cohort study of children recovering from cardiac surgery (n = 75) showed significantly higher extubation success, shorter duration of ventilation and PICU length of stay, and a reduction in sedative use. Our systematic review presents weak evidence that NAVA may shorten the duration of ventilation and PICU length of stay, and reduce the requirement of sedatives. However, further RCTs are required to more fully assess the effect of NAVA on clinical outcomes and treatment costs in ventilated children.
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