Patient-ventilator asynchrony

Marcelo Alcantara Holanda, Renata Dos Santos Vasconcelos, Juliana Carvalho Ferreira, Bruno Valle Pinheiro, Marcelo Alcantara Holanda, Renata Dos Santos Vasconcelos, Juliana Carvalho Ferreira, Bruno Valle Pinheiro

Abstract

Patient-v entilator asynchrony (PVA) is a mismatch between the patient, regarding time, flow, volume, or pressure demands of the patient respiratory system, and the ventilator, which supplies such demands, during mechanical ventilation (MV). It is a common phenomenon, with incidence rates ranging from 10% to 85%. PVA might be due to factors related to the patient, to the ventilator, or both. The most common PVA types are those related to triggering, such as ineffective effort, auto-triggering, and double triggering; those related to premature or delayed cycling; and those related to insufficient or excessive flow. Each of these types can be detected by visual inspection of volume, flow, and pressure waveforms on the mechanical ventilator display. Specific ventilatory strategies can be used in combination with clinical management, such as controlling patient pain, anxiety, fever, etc. Deep sedation should be avoided whenever possible. PVA has been associated with unwanted outcomes, such as discomfort, dyspnea, worsening of pulmonary gas exchange, increased work of breathing, diaphragmatic injury, sleep impairment, and increased use of sedation or neuromuscular blockade, as well as increases in the duration of MV, weaning time, and mortality. Proportional assist ventilation and neurally adjusted ventilatory assist are modalities of partial ventilatory support that reduce PVA and have shown promise. This article reviews the literature on the types and causes of PVA, as well as the methods used in its evaluation, its potential implications in the recovery process of critically ill patients, and strategies for its resolution.

Figures

Figure 1. Flow and pressure waveforms, respectively,…
Figure 1. Flow and pressure waveforms, respectively, illustrating two simulated types of ineffective triggering. The first two waveforms represent a patient without problems in respiratory mechanics, with a weak spontaneous effort (Pmus) because of respiratory muscle weakness or decreased neural drive. The bottom two waveforms represent a patient with airflow obstruction and difficulty in triggering some breaths because of the presence of auto-positive endexpiratory pressure, even with a muscle effort that is “physiological” but unable to trigger ventilator breaths. In both cases, pressure-controlled ventilation (pressure sensitivity of −2 cmH2O) was used. The dots on the waveforms indicate ineffective efforts. Paw: airway pressure; and Pmus: muscle pressure. Source: Xlung®.
Figure 2. Volume, flow and pressure waveforms,…
Figure 2. Volume, flow and pressure waveforms, respectively, illustrating two simulated types of auto-triggering. The first three waveforms represent a patient on pressure-support ventilation with flow sensitivity. The system with a leak causes the onset of flow-triggered breaths, without patient effort (Pmus = 0). The bottom three waveforms represent a patient on pressure-controlled ventilation,* without respiratory muscle effort, but showing regular flow and pressure oscillations, with a respiratory rate of approximately 80 breaths/min, corresponding to his/her heart rate. Pressure sensitivity was changed to flow sensitivity. The increase in the total respiratory rate was due to triggers induced by transmission of flow oscillations because of cardiac activity. Vol.: volume; and Paw: airway pressure. Source: Xlung®.
Figure 3. Volume, flow, and pressure waveforms,…
Figure 3. Volume, flow, and pressure waveforms, respectively, illustrating two simulations of asynchrony. The first three waveforms represent a case in which, because of patient neural inspiratory time, which is longer than the ventilator inspiratory time, the first breath is always triggered by the patient, during volume-controlled ventilation. The dots indicate stacked tidal volume caused by double triggering. The bottom three waveforms represent a case of reverse triggering due to respiratory muscle effort triggered by reflex mechanisms resulting from a ventilator-delivered breath, during pressure-controlled ventilation. Note, in both cases, stacked tidal volume and increased airway pressure during asynchrony. The dots indicate reverse triggering. Paw: airway pressure; and Pmus: muscle pressure. Source: Xlung®.
Figure 4. Flow and pressure waveforms, respectively,…
Figure 4. Flow and pressure waveforms, respectively, illustrating two types of cycling asynchrony simulated during pressure support ventilation. The first two waveforms represent a patient with COPD. Asynchrony is corrected by increasing the threshold percentage of peak inspiratory flow for termination of inspiration. The bottom two waveforms represent a patient with restrictive lung disease experiencing premature cycling. Asynchrony is attenuated by decreasing the cycling threshold percentage of peak flow. The dots indicate cycling during pressure support ventilation. Paw: airway pressure; and Pmus: muscle pressure. Source: Xlung®.
Figure 5. Volume, flow, and pressure waveforms,…
Figure 5. Volume, flow, and pressure waveforms, respectively, illustrating simulation of correction of flow asynchrony and volume asynchrony (air hunger), evident in the second breath, during VCV. The application of PCV from the third breath onward enabled delivery of flow and tidal volume. The patient responded with decreased muscle contraction (Pmus) from the fourth breath onward. Note a slight airway pressure overshoot at the end of breath during PCV (arrow), attenuated by better adaptation of the patient. The dots indicate free-flow delivery during PCV. VCV: volume-controlled ventilation; PCV: pressure-controlled ventilation; Paw: airway pressure;; and Pmus: muscle pressure. Source: Xlung®.

References

    1. Wunsch H, Linde-Zwirble WT, Angus DC, Hartman ME, Milbrandt EB, Kahn JM. The epidemiology of mechanical ventilation use in the United States. Crit Care Med. 2010;38(10):1947–1953. doi: 10.1097/CCM.0b013e3181ef4460.
    1. Barbas CS, Isola AM, Farias AM, Cavalcanti AB, Gama AM, Duarte AC. Brazilian recommendations of mechanical ventilation 2013 Part I. Rev Bras Ter Intensiva. 2014;26(2):89–121. doi: 10.5935/0103-507X.20140017.
    1. Vasconcelos Rdos S, Melo LH, Sales RP, Marinho LS, Deulefeu FC, Reis RC. Effect of an automatic triggering and cycling system on comfort and patient-ventilator synchrony during pressure support ventilation. Respiration. 2013;86(6):497–503. doi: 10.1159/000353256.
    1. Chao DC, Scheinhorn DJ, Stearn-Hassenpflug M. Patient-ventilator trigger asynchrony in prolonged mechanical ventilation. Chest. 1997;112(6):1592–1599. doi: 10.1378/chest.112.6.1592.
    1. Thille AW, Rodriguez P, Cabello B, Lellouche F, Brochard L. Patientventilator asynchrony during assisted mechanical ventilation. Intensive Care Med. 2006;32(10):1515–1522. doi: 10.1007/s00134-006-0301-8.
    1. de Wit M, Pedram S, Best AM, Epstein SK. Observational study of patient-ventilator asynchrony and relationship to sedation level. J Crit Care. 2009;24(1):74–80. doi: 10.1016/j.jcrc.2008.08.011.
    1. Colombo D, Cammarota G, Alemani M, Carenzo L, Barra FL, Vaschetto R. Efficacy of ventilator waveforms observation in detecting patient-ventilator asynchrony. Crit Care Med. 2011;39(11):2452–2457. doi: 10.1097/CCM.0b013e318225753c.
    1. Alexopoulou C, Kondili E, Plataki M, Georgopoulos D. Patientventilator synchrony and sleep quality with proportional assist and pressure support ventilation. Intensive Care Med. 2013;39(6):1040–1047. doi: 10.1007/s00134-013-2850-y.
    1. Branson RD. Patient-ventilator interaction the last 40 years. Respir Care. 2011;56(1):15–24. doi: 10.4187/respcare.00937.
    1. Nava S, Bruschi C, Fracchia C, Braschi A, Rubini F. Patient-ventilator interaction and inspiratory effort during pressure support ventilation in patients with different pathologies. Eur Respir J. 1997;10(1):177–183. doi: 10.1183/09031936.97.10010177.
    1. Vasconcelos RS, Sales RP, Melo LHP, Marinho LS, Bastos VP, Nogueira ADN. Influences of Duration of Inspiratory Effort, Respiratory Mechanics, and Ventilator Type on Asynchrony With Pressure Support and Proportional Assist Ventilation. Respir Care. 2017;62(5):550–557. doi: 10.4187/respcare.05025.
    1. Ferreira JC, Chipman DW, Hill NS, Kacmarek RM. Bilevel vs ICU ventilators providing noninvasive ventilation effect of system leaks: a COPD lung model comparison. Chest. 2009;136(2):448–456. doi: 10.1378/chest.08-3018.
    1. Jubran A, Van de Graaff WB, Tobin MJ. Variability of patient-ventilator interaction with pressure support ventilation in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1995;152(1):129–136. doi: 10.1164/ajrccm.152.1.7599811.
    1. Pohlman MC, McCallister KE, Schweickert WD, Pohlman AS, Nigos CP, Krishnan JA. Excessive tidal volume from breath stacking during lung-protective ventilation for acute lung injury. Crit Care Med. 2008;36(11):3019–3023. doi: 10.1097/CCM.0b013e31818b308b.
    1. Slutsky AS, Ranieri VM. Ventilator-induced lung injury. N Engl J Med. 2013;369(22):2126–2136. doi: 10.1056/NEJMra1208707.
    1. Nava S, Bruschi C, Rubini F, Palo A, Iotti G, Braschi A. Respiratory response and inspiratory effort during pressure support ventilation in COPD patients. Intensive Care Med. 1995;21(11):871–879. doi: 10.1007/BF01712327.
    1. Marini JJ, Rodriguez RM, Lamb V. The inspiratory workload of patientinitiated mechanical ventilation. Am Rev Respir Dis. 1986;134(5):902–909. doi: 10.1164/arrd.1986.134.5.902.
    1. MacIntyre NR, McConnell R, Cheng KC, Sane A. Patient-ventilator flow dyssynchrony flow-limited versus pressure-limited breaths. Crit Care Med. 1997;25(10):1671–1677. doi: 10.1097/00003246-199710000-00016.
    1. Akoumianaki E, Lyazidi A, Rey N, Matamis D, Perez-Martinez N, Giraud R. Mechanical ventilation-induced reverse-triggered breaths A frequently unrecognized form of neuromechanical coupling. Chest. 2013;143(4):927–938. doi: 10.1378/chest.12-1817.
    1. Beitler JR, Sands SA, Loring SH, Owens RL, Malhotra A, Spragg RG. Quantifying unintended exposure to high tidal volumes from breath stacking dyssynchrony in ARDS the BREATHE criteria. Intensive Care Med. 2016;42(9):1427–1436. doi: 10.1007/s00134-016-4423-3.
    1. Yonis H, Gobert F, Tapponnier R, Guérin C. Reverse triggering in a patient with ARDS. Intensive Care Med. 2015;41(9):1711–1712. doi: 10.1007/s00134-015-3702-8.
    1. Blanch L, Villagra A, Sales B, Montanya J, Lucangelo U, Luján M. Asynchronies during mechanical ventilation are associated with mortality. Intensive Care Med. 2015;41(4):633–641. doi: 10.1007/s00134-015-3692-6.
    1. Gilstrap D, MacIntyre N. Patient-ventilator interactions Implications for clinical management. Am J Respir Crit Care Med. 2013;188(9):1058–1068. doi: 10.1164/rccm.201212-2214CI.
    1. Schmidt M, Demoule A, Polito A, Porchet R, Aboab J, Siami S. Dyspnea in mechanically ventilated critically ill patients. Crit Care Med. 2011;39(9):2059–2065. doi: 10.1097/CCM.0b013e31821e8779.
    1. Liotti M, Brannan S, Egan G, Shade R, Madden L, Abplanalp B. Brain responses associated with consciousness of breathlessness (air hunger) Proc Natl Acad Sci USA. 2001;98(4):2035–2040. doi: 10.1073/pnas.98.4.2035.
    1. Yonis H, Crognier L, Conil JM, Serres I, Rouget A, Virtos M. Patient-ventilator synchrony in Neurally Adjusted Ventilatory Assist (NAVA) and Pressure Support Ventilation (PSV) a prospective observational study. BMC Anesthesiol. 2015;15:117–117. doi: 10.1186/s12871-015-0091-z.
    1. Branson RD, Blakeman TC, Robinson BR. Asynchrony and dyspnea. Respir Care. 2013;58(6):973–989. doi: 10.4187/respcare.02507.
    1. Sieck GC, Ferreira LF, Reid MB, Mantilla CB. Mechanical properties of respiratory muscles. Compr Physiol. 2013;3(4):1553–1567. doi: 10.1002/cphy.c130003.
    1. Murias G, Lucangelo U, Blanch L. Patient-ventilator asynchrony. Curr Opin Crit Care. 2016;22(1):53–59. doi: 10.1097/MCC.0000000000000270.
    1. Mellott KG, Grap MJ, Munro CL, Sessler CN, Wetzel PA, Nilsestuen JO. Patient ventilator asynchrony in critically ill adults frequency and types. Heart Lung. 2014;43(3):231–243. doi: 10.1016/j.hrtlng.2014.02.002.
    1. Vaschetto R, Cammarota G, Colombo D, Longhini F, Grossi F, Giovanniello A. Effects of propofol on patient-ventilator synchrony and interaction during pressure support ventilation and neurally adjusted ventilatory assist. Crit Care Med. 2014;42(1):74–82. doi: 10.1097/CCM.0b013e31829e53dc.
    1. de Wit M, Miller KB, Green DA, Ostman HE, Gennings C, Epstein SK. Ineffective triggering predicts increased duration of mechanical ventilation. Crit Care Med. 2009;37(10):2740–2745.
    1. Conti G, Ranieri VM, Costa R, Garratt C, Wighton A, Spinazzola G. Effects of dexmedetomidine and propofol on patient-ventilator interaction in difficult-to-wean, mechanically ventilated patients a prospective, open-label, randomised, multicentre study. Crit Care. 2016;20(1):206–206. doi: 10.1186/s13054-016-1386-2.
    1. Chanques G, Kress JP, Pohlman A, Patel S, Poston J, Jaber S. Impact of ventilator adjustment and sedation-analgesia practices on severe asynchrony in patients ventilated in assist-control mode. Crit Care Med. 2013;41(9):2177–2187. doi: 10.1097/CCM.0b013e31828c2d7a.
    1. Drouot X, Bridoux A, Thille AW, Roche-Campo F, Cordoba-Izquierdo A, Katsahian S. Sleep continuity a new metric to quantify disrupted hypnograms in non-sedated intensive care unit patients. Crit Care. 2014;18(6):628–628. doi: 10.1186/s13054-014-0628-4.
    1. Rittayamai N, Wilcox E, Drouot X, Mehta S, Goffi A, Brochard L. Positive and negative effects of mechanical ventilation on sleep in the ICU a review with clinical recommendations. Intensive Care Med. 2016;42(4):531–541. doi: 10.1007/s00134-015-4179-1.
    1. Dres M, Rittayamai N, Brochard L. Monitoring patient-ventilator asynchrony. Curr Opin Crit Care. 2016;22(3):246–253. doi: 10.1097/MCC.0000000000000307.
    1. Roche-Campo F, Thille AW, Drouot X, Galia F, Margarit L, CórdobaIzquierdo A. Comparison of sleep quality with mechanical versus spontaneous ventilation during weaning of critically III tracheostomized patients. Crit Care Med. 2013;41(7):1637–1644. doi: 10.1097/CCM.0b013e318287f569.
    1. Gilstrap D, Davies J. Patient-Ventilator Interactions. Clin Chest Med. 2016;37(4):669–681. doi: 10.1016/j.ccm.2016.07.007.
    1. Kacmarek RM. Proportional assist ventilation and neurally adjusted ventilatory assist. Respir Care. 2011;56(2):140–148. doi: 10.4187/respcare.01021.
    1. Terzi N, Piquilloud L, Rozé H, Mercat A, Lofaso F, Delisle S. Clinical review Update on neurally adjusted ventilatory assist--report of a round-table conference. Crit Care. 2012;16(3):225–225. doi: 10.1186/cc11297.
    1. Piquilloud L, Vignaux L, Bialais E, Roeseler J, Sottiaux T, Laterre PF. Neurally adjusted ventilatory assist improves patient-ventilator interaction. Intensive Care Med. 2011;37(2):263–271. doi: 10.1007/s00134-010-2052-9.
    1. Spahija J, de Marchie M, Albert M, Bellemare P, Delisle S, Beck J. Patient-ventilator interaction during pressure support ventilation and neurally adjusted ventilatory assist. Crit Care Med. 2010;38(2):518–526. doi: 10.1097/CCM.0b013e3181cb0d7b.
    1. Terzi N, Pelieu I, Guittet L, Ramakers M, Seguin A, Daubin C. Neurally adjusted ventilatory assist in patients recovering spontaneous breathing after acute respiratory distress syndrome physiological evaluation. Crit Care Med. 2010;38(9):1830–1837. doi: 10.1097/CCM.0b013e3181eb3c51.
    1. Colombo D, Cammarota G, Bergamaschi V, De Lucia M, Corte FD, Navalesi P. Physiologic response to varying levels of pressure support and neurally adjusted ventilatory assist in patients with acute respiratory failure. Intensive Care Med. 2008;34(11):2010–2018. doi: 10.1007/s00134-008-1208-3.
    1. Barbas CS, Ísola AM, De Farias AM, Cavalcanti AB, Gama AM, Duarte AC. Brazilian recommendations of mechanical ventilation 2013 Part 2. Rev Bras Ter Intensiva. 2014;26(3):215–239. doi: 10.5935/0103-507X.20140034.
    1. Demoule A, Clavel M, Rolland-Debord C, Perbet S, Terzi N, Kouatchet A. Neurally adjusted ventilatory assist as an alternative to pressure support ventilation in adults a French multicentre randomized trial. Intensive Care Med. 2016;42(11):1723–1732. doi: 10.1007/s00134-016-4447-8.
    1. Xirouchaki N, Kondili E, Vaporidi K, Xirouchakis G, Klimathianaki M, Gavriilidis G. Proportional assist ventilation with load-adjustable gain factors in critically ill patients comparison with pressure support. Intensive Care Med. 2008;34(11):2026–2034. doi: 10.1007/s00134-008-1209-2.
    1. Costa R, Spinazzola G, Cipriani F, Ferrone G, Festa O, Arcangeli A. A physiologic comparison of proportional assist ventilation with load-adjustable gain factors (PAV+) versus pressure support ventilation (PSV) Intensive Care Med. 2011;37(9):1494–1500. doi: 10.1007/s00134-011-2297-y.
    1. Kondili E, Prinianakis G, Alexopoulou C, Vakouti E, Klimathianaki M, Georgopoulos D. Respiratory load compensation during mechanical ventilation--proportional assist ventilation with loadadjustable gain factors versus pressure support. Intensive Care Med. 2006;32(5):692–699. doi: 10.1007/s00134-006-0110-0.
    1. Ramirez II, Arellano DH, Adasme RS, Landeros JM, Salinas FA, Vargas AG. Ability of ICU Health-Care Professionals to Identify Patient-Ventilator Asynchrony Using Waveform Analysis. Respir Care. 2017;62(2):144–149. doi: 10.4187/respcare.04750.
    1. Piquilloud L, Jolliet P, Revelly JP. Automated detection of patient-ventilator asynchrony new tool or new toy? Crit Care. 2013;17(6):1015–1015. doi: 10.1186/cc13122.
    1. Nguyen QT, Pastor D, Lellouche F, L'her E. Mechanical ventilation system monitoring automatic detection of dynamic hyperinflation and asynchrony. Conf Proc IEEE Eng Med Biol Soc. 2013;2013:520710–520710.
    1. Gutierrez G, Ballarino GJ, Turkan H, Abril J, De La Cruz L, Edsall C. Automatic detection of patient-ventilator asynchrony by spectral analysis of airway flow. Crit Care. 2011;15(4):R167–R167. doi: 10.1186/cc10309.
    1. Sinderby C, Liu S, Colombo D, Camarotta G, Slutsky AS, Navalesi P. An automated and standardized neural index to quantify patient-ventilator interaction. Crit Care. 2013;17(5):R239–R239. doi: 10.1186/cc13063.
    1. Blanch L, Sales B, Montanya J, Lucangelo U, Garcia-Esquirol O, Villagra A. Validation of the Better Care(r) system to detect ineffective efforts during expiration in mechanically ventilated patients a pilot study. Intensive Care Med. 2012;38(5):772–780. doi: 10.1007/s00134-012-2493-4.
    1. Tallo FS, de Campos Vieira Abib S, de Andrade Negri AJ, Cesar P, Lopes RD, Lopes AC. Evaluation of self-perception of mechanical ventilation knowledge among Brazilian final-year medical students, residents and emergency physicians. Clinics (Sao Paulo) 2017;72(2):65–70. doi: 10.6061/clinics/2017(02)01.
    1. Heisler M. Hospitalists and intensivists partners in caring for the critically ill--the time has come. J Hosp Med. 2010;5(1):1–3. doi: 10.1002/jhm.580.
    1. Lino JA, Gomes GC, Sousa ND, Carvalho AK, Diniz ME, Viana AB., Junior A Critical Review of Mechanical Ventilation Virtual Simulators Is It Time to Use Them? JMIR Med Educ. 2016;2(1):e8. doi: 10.2196/mededu.5350.
    1. Lynch-Smith D, Thompson CL, Pickering RG, Wan JY. Education on Patient-Ventilator Synchrony, Clinicians' Knowledge Level, and Duration of Mechanical Ventilation. Am J Crit Care. 2016;25(6):545551–545551. doi: 10.4037/ajcc2016623.

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