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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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Kneyber MCJ, Cheifetz IM. Mechanical ventilation during pediatric extracorporeal life support. Curr Opin Pediatr 2023; 35:596-602. [PMID: 37497765 DOI: 10.1097/mop.0000000000001277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
PURPOSE OF REVIEW To discuss the role of ventilator induced lung injury (VILI) and patient self-inflicted lung injury in ventilated children supported on extracorporeal membrane oxygenation (ECMO). RECENT FINDINGS While extracorporeal life support is used routinely used every day around the globe to support neonatal, pediatric, and adult patients with refractory cardiac and/or respiratory failure, the optimal approach to mechanical ventilation, especially for those with acute respiratory distress syndrome (ARDS), remains unknown and controversial. Given the lack of definitive data in this population, one must rely on available evidence in those with ARDS not supported with ECMO and extrapolate adult observations. Ventilatory management should include, as a minimum standard, limiting inspiratory and driving pressures, providing a sufficient level of positive end-expiratory pressure, and setting a low rate to reduce mechanical power. Allowing for spontaneous breathing and use of pulmonary specific ancillary treatment modalities must be individualized, while balancing the risk and benefits. Future studies delineating the best strategies for optimizing MV during pediatric extracorporeal life support are much needed. SUMMARY Future investigations will hopefully provide the needed evidence and better understanding of the overall goal of reducing mechanical ventilation intensity to decrease risk for VILI and promote lung recovery for those supported with ECMO.
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Affiliation(s)
- Martin C J Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen
- Critical care, Anesthesiology, Peri-operative & Emergency medicine (CAPE), University of Groningen, Groningen, The Netherlands
| | - Ira M Cheifetz
- Department of Pediatrics, Rainbow Babies and Children's Hospital and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Shimatani T, Kyogoku M, Ito Y, Takeuchi M, Khemani RG. Fundamental concepts and the latest evidence for esophageal pressure monitoring. J Intensive Care 2023; 11:22. [PMID: 37217973 DOI: 10.1186/s40560-023-00671-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 05/16/2023] [Indexed: 05/24/2023] Open
Abstract
Transpulmonary pressure is an essential physiologic concept as it reflects the true pressure across the alveoli, and is a more precise marker for lung stress. To calculate transpulmonary pressure, one needs an estimate of both alveolar pressure and pleural pressure. Airway pressure during conditions of no flow is the most widely accepted surrogate for alveolar pressure, while esophageal pressure remains the most widely measured surrogate marker for pleural pressure. This review will cover important concepts and clinical applications for esophageal manometry, with a particular focus on how to use the information from esophageal manometry to adjust or titrate ventilator support. The most widely used method for measuring esophageal pressure uses an esophageal balloon catheter, although these measurements can be affected by the volume of air in the balloon. Therefore, when using balloon catheters, it is important to calibrate the balloon to ensure the most appropriate volume of air, and we discuss several methods which have been proposed for balloon calibration. In addition, esophageal balloon catheters only estimate the pleural pressure over a certain area within the thoracic cavity, which has resulted in a debate regarding how to interpret these measurements. We discuss both direct and elastance-based methods to estimate transpulmonary pressure, and how they may be applied for clinical practice. Finally, we discuss a number of applications for esophageal manometry and review many of the clinical studies published to date which have used esophageal pressure. These include the use of esophageal pressure to assess lung and chest wall compliance individually which can provide individualized information for patients with acute respiratory failure in terms of setting PEEP, or limiting inspiratory pressure. In addition, esophageal pressure has been used to estimate effort of breathing which has application for ventilator weaning, detection of upper airway obstruction after extubation, and detection of patient and mechanical ventilator asynchrony.
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Affiliation(s)
- Tatsutoshi Shimatani
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima-shi, Hiroshima, Japan.
- Department of Critical Care Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
| | - Miyako Kyogoku
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, 840 Murodo-cho, Osaka, Izumi, Japan
- Department of Critical Care Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yukie Ito
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, 840 Murodo-cho, Osaka, Izumi, Japan
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, 840 Murodo-cho, Osaka, Izumi, Japan
- Department of Critical Care Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Robinder G Khemani
- Pediatric ICU, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd., CA, Los Angeles, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, 1975, USA
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Abstract
Intermittent mandatory ventilation (IMV) is one kind of breath sequence used to classify a mode of ventilation. IMV is defined as the ability for spontaneous breaths (patient triggered and patient cycled) to exist between mandatory breaths (machine triggered or machine cycled). Over the course of more than a century, IMV has evolved into 4 distinct varieties, each with its own advantages and disadvantages in serving the goals of mechanical ventilation (ie, safety, comfort, and liberation). The purpose of this paper is to describe the evolution of IMV, review relevant supporting evidence, and discuss the rationales for each of the 4 varieties. Also included is a brief overview of the background information required for a proper perspective of the purpose and design of the innovations. Understanding these different forms of IMV is essential to recognizing the similarities and differences among many dozens of different modes of ventilation. This recognition is important for clinical application, education of caregivers, and research in mechanical ventilation.
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Affiliation(s)
- Robert L Chatburn
- Enterprise Respiratory Care Research, Cleveland Clinic, Cleveland, Ohio; and Department of Medicine, Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio.
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Rodrigues A, Telias I, Damiani LF, Brochard L. Reverse Triggering during Controlled Ventilation: From Physiology to Clinical Management. Am J Respir Crit Care Med 2023; 207:533-543. [PMID: 36470240 DOI: 10.1164/rccm.202208-1477ci] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Reverse triggering dyssynchrony is a frequent phenomenon recently recognized in sedated critically ill patients under controlled ventilation. It occurs in at least 30-55% of these patients and often occurs in the transition from fully passive to assisted mechanical ventilation. During reverse triggering, patient inspiratory efforts start after the passive insufflation by mechanical breaths. The most often referred mechanism is the entrainment of the patient's intrinsic respiratory rhythm from the brainstem respiratory centers to periodic mechanical insufflations from the ventilator. However, reverse triggering might also occur because of local reflexes without involving the respiratory rhythm generator in the brainstem. Reverse triggering is observed during the acute phase of the disease, when patients may be susceptible to potential deleterious consequences of injurious or asynchronous efforts. Diagnosing reverse triggering might be challenging and can easily be missed. Inspection of ventilator waveforms or more sophisticated methods, such as the electrical activity of the diaphragm or esophageal pressure, can be used for diagnosis. The occurrence of reverse triggering might have clinical consequences. On the basis of physiological data, reverse triggering might be beneficial or injurious for the diaphragm and the lung, depending on the magnitude of the inspiratory effort. Reverse triggering can cause breath-stacking and loss of protective lung ventilation when triggering a second cycle. Little is known about how to manage patients with reverse triggering; however, available evidence can guide management on the basis of physiological principles.
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Affiliation(s)
- Antenor Rodrigues
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
| | - Irene Telias
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada; and
| | - L Felipe Damiani
- Departamento Ciencias de la Salud, Carrera de Kinesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Laurent Brochard
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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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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Reply: Not All Breaths That Follow a Ventilator Cycle Are Reverse Triggering. Ann Am Thorac Soc 2021; 18:1264-1266. [PMID: 33780645 PMCID: PMC8328360 DOI: 10.1513/annalsats.202103-322le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Not All Breaths That Follow a Ventilator Cycle Are Reverse Triggering. Ann Am Thorac Soc 2021; 18:1263-1264. [PMID: 33780649 PMCID: PMC8328359 DOI: 10.1513/annalsats.202102-120le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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