Information conveyed by electrical diaphragmatic activity during unstressed, stressed and assisted spontaneous breathing: a physiological study

Lise Piquilloud, François Beloncle, Jean-Christophe M Richard, Jordi Mancebo, Alain Mercat, Laurent Brochard, Lise Piquilloud, François Beloncle, Jean-Christophe M Richard, Jordi Mancebo, Alain Mercat, Laurent Brochard

Abstract

Background: The electrical activity of the crural diaphragm (Eadi), a surrogate of respiratory drive, can now be measured at the bedside in mechanically ventilated patients with a specific catheter. The expected range of Eadi values under stressed or assisted spontaneous breathing is unknown. This study explored Eadi values in healthy subjects during unstressed (baseline), stressed (with a resistance) and assisted spontaneous breathing. The relation between Eadi and inspiratory effort was analyzed.

Methods: Thirteen healthy male volunteers were included in this randomized crossover study. Eadi and esophageal pressure (Peso) were recorded during unstressed and stressed spontaneous breathing and under assisted ventilation delivered in pressure support (PS) at low and high assist levels and in neurally adjusted ventilatory assist (NAVA). Overall eight different situations were assessed in each participant (randomized order). Peak, mean and integral of Eadi, breathing pattern, esophageal pressure-time product (PTPeso) and work of breathing (WOB) were calculated offline.

Results: Median [interquartile range] peak Eadi at baseline was 17 [13-22] μV and was above 10 μV in 92% of the cases. Eadimax defined as Eadi measured at maximal inspiratory capacity reached 90 [63 to 99] μV. Median peak Eadi/Eadimax ratio was 16.8 [15.6-27.9]%. Compared to baseline, respiratory rate and minute ventilation were decreased during stressed non-assisted breathing, whereas peak Eadi and PTPeso were increased. During unstressed assisted breathing, peak Eadi decreased during high-level PS compared to unstressed non-assisted breathing and to NAVA (p = 0.047). During stressed breathing, peak Eadi was lower during all assisted ventilation modalities compared to stressed non-assisted breathing. During assisted ventilation, across the different conditions, peak Eadi changed significantly, whereas PTPeso and WOB/min were not significantly modified. Finally, Eadi signal was still present even when Peso signal was suppressed due to high assist levels.

Conclusion: Eadi analysis provides complementary information compared to respiratory pattern and to Peso monitoring, particularly in the presence of high assist levels. Trial registration The study was registered as NCT01818219 in clinicaltrial.gov. Registered 28 February 2013.

Keywords: Assisted ventilation; Electrical activity of the diaphragm; Esophageal pressure; Inspiratory effort; Respiratory drive; Respiratory pattern; Work of breathing.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Breathing conditions recorded in a randomized order. PS pressure support ventilation, NAVA neurally adjusted ventilatory assist
Fig. 2
Fig. 2
Illustration of the measurements performed offline from the recorded curves (example of assisted ventilation). Tip: Pneumatic inspiratory time, Ttot: Total duration of a respiratory cycle, Tin: neural inspiratory time or time between initial increase in Eadi signal and peak Eadi, Tiex: time delay between maximal Eadi value and end of inspiratory flow. Peak Eadi: maximal Eadi value during one breath, Mean Eadi: mean Eadi value during Eadi increase related to inspiration, Eadi global integral: area under the curve (integral) of the global Eadi signal, Eadi integral peak: area under the curve of Eadi signal censured at the peak, PTPeso: Esophageal pressure–time product
Fig. 3
Fig. 3
Effect of unstressed assisted ventilation on peak electrical activity of the diaphragm (peak Eadi). SB unstressed (without resistance) spontaneous non-assisted breathing, PSV pressure support ventilation, NAVA neurally adjusted ventilatory assist. The data of all the participants are displayed in the figure. Patients for whom all the conditions were available are represented as white circles. Patients for whom one or more conditions could not be recorded are represented as gray triangles. Only the subjects represented as white circles were considered for median calculations and Friedman analysis
Fig. 4
Fig. 4
Effect of unstressed assisted ventilation on MV (a), RR (b), VT (c) and PTPeso/min (d). MV minute ventilation, RR respiratory rate, VT tidal volume, PTPeso/min esophageal pressure–time product by minute, SB unstressed (without resistance) spontaneous non-assisted breathing, PSV pressure support ventilation, NAVA neurally adjusted ventilator assist. The data of all the participants are displayed in the figure. Patients for whom all the conditions were available are represented as white circles. Patients for whom one or more conditions could not be recorded are represented as gray triangles. Only the patients represented as white circles were considered for median calculations and Friedman analyses
Fig. 5
Fig. 5
Effect of stressed assisted ventilation on peak electrical activity of the diaphragm (peak Eadi). SBr stressed (with resistance) spontaneous non-assisted breathing, PSV pressure support ventilation, NAVA neurally adjusted ventilatory assist. The data of all the participants are displayed in the figure. Patients for whom all the conditions were available are represented as white circles. Patients for whom one or more conditions could not be recorded are represented as gray triangles. Only the patients represented as white circles were considered for median calculations and Friedman analysis
Fig. 6
Fig. 6
Effect of stressed assisted ventilation on MV (a), RR (b), VT (c) and PTPeso/min (d). MV minute ventilation, RR respiratory rate, VT tidal volume, PTPeso/min esophageal pressure–time product by minute. SBr spontaneous non-assisted breathing in the presence of the resistance, PSV pressure support ventilation. NAVA neurally adjusted ventilatory assist. The data of all the participants are displayed in the figure. Patients for whom all the conditions were available are represented as white circles. Patients for whom one or more conditions could not be recorded are represented as gray triangles. Only the patients represented as white circles were considered for median calculations and Friedman analyses

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