Ventilator dyssynchrony - Detection, pathophysiology, and clinical relevance: A Narrative review

Peter D Sottile, David Albers, Bradford J Smith, Marc M Moss, Peter D Sottile, David Albers, Bradford J Smith, Marc M Moss

Abstract

Mortality associated with the acute respiratory distress syndrome remains unacceptably high due in part to ventilator-induced lung injury (VILI). Ventilator dyssynchrony is defined as the inappropriate timing and delivery of a mechanical breath in response to patient effort and may cause VILI. Such deleterious patient-ventilator interactions have recently been termed patient self-inflicted lung injury. This narrative review outlines the detection and frequency of several different types of ventilator dyssynchrony, delineates the different mechanisms by which ventilator dyssynchrony may propagate VILI, and reviews the potential clinical impact of ventilator dyssynchrony. Until recently, identifying ventilator dyssynchrony required the manual interpretation of ventilator pressure and flow waveforms. However, computerized interpretation of ventilator waive forms can detect ventilator dyssynchrony with an area under the receiver operating curve of >0.80. Using such algorithms, ventilator dyssynchrony occurs in 3%-34% of all breaths, depending on the patient population. Moreover, two types of ventilator dyssynchrony, double-triggered and flow-limited breaths, are associated with the more frequent delivery of large tidal volumes >10 mL/kg when compared with synchronous breaths (54% [95% confidence interval (CI), 47%-61%] and 11% [95% CI, 7%-15%]) compared with 0.9% (95% CI, 0.0%-1.9%), suggesting a role in propagating VILI. Finally, a recent study associated frequent dyssynchrony-defined as >10% of all breaths-with an increase in hospital mortality (67 vs. 23%, P = 0.04). However, the clinical significance of ventilator dyssynchrony remains an area of active investigation and more research is needed to guide optimal ventilator dyssynchrony management.

Keywords: Acute respiratory distress syndrome; patient self-inflicted lung injury; ventilator dyssynchrony; ventilator-induced lung injury.

Conflict of interest statement

There are no conflicts of interest.

Copyright: © 2020 Annals of Thoracic Medicine.

Figures

Figure 1
Figure 1
Representative types of ventilator dyssynchrony – Examples of some types of commonly observed ventilator dyssynchronies. All examples demonstrate flow (L/min), airway pressure (cm H2O), esophageal pressure (cm H2O), and volume (ml)
Figure 2
Figure 2
Examples of transpulmonary pressures with and without spontaneous effort – During a pressure- or volume-controlled mechanical breath in a paralyzed patient (left), the transpulmonary pressure is the difference between the airway pressure and pleural pressures (25 = 30 - 5) and transvascular pressure is the difference between the capillary pressure and pleural pressures (5=10-5). In a spontaneously breathing mechanically ventilated patient (right), airway pressure is constant but pleural pressure is negative. This results in both increased transpulmonary pressure (45 = 30--15) and transvascular pressures (25=10--15), which may worsen lung injury and pulmonary edema. Paw: Airway pressure, Ppl: Pleural pressure, Pcap: Capillary pressure, PL: Transpulmonary pressure

References

    1. Bellani G, Laffey JG, Pham T, Fan E, Brochard L, Esteban A, et al. Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA. 2016;315:788–800.
    1. Webb HH, Tierney DF. Experimental pulmonary edema due to intermittent positive pressure ventilation with high inflation pressures. Protection by positive end-expiratory pressure. Am Rev Respir Dis. 1974;110:556–65.
    1. Slutsky AS, Ranieri VM. Ventilator-induced lung injury. N Engl J Med. 2013;369:2126–36.
    1. Acute Respiratory Distress Syndrome Network. Brower RG, Matthay MA, Morris A, Schoenfeld D, Thompson BT, et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342:1301–8.
    1. Brower RG, Lanken PN, MacIntyre N, Matthay MA, Morris A, Ancukiewicz M, et al. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med. 2004;351:327–36.
    1. Futier E, Constantin JM, Paugam-Burtz C, Pascal J, Eurin M, Neuschwander A, et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Engl J Med. 2013;369:428–37.
    1. Guay J, Ochroch EA. Intraoperative use of low volume ventilation to decrease postoperative mortality, mechanical ventilation, lengths of stay and lung injury in patients without acute lung injury. Cochrane Database Syst Rev. 2018;9:7.
    1. Determann RM, Royakkers A, Wolthuis EK, Vlaar AP, Choi G, Paulus F, et al. Ventilation with lower tidal volumes as compared with conventional tidal volumes for patients without acute lung injury: A preventive randomized controlled trial. Crit Care. 2010;14:R1.
    1. Gilstrap D, MacIntyre N. Patient-ventilator interactions. Implications for clinical management. Am J Respir Crit Care Med. 2013;188:1058–68.
    1. MacIntyre N, Nishimura M, Usada Y, Tokioka H, Takezawa J, Shimada Y. The Nagoya conference on system design and patient-ventilator interactions during pressure support ventilation. Chest. 1990;97:1463–6.
    1. Brochard L, Slutsky A, Pesenti A. Mechanical ventilation to minimize progression of lung injury in acute respiratory failure. Am J Respir Crit Care Med. 2017;195:438–42.
    1. Dres M, Rittayamai N, Brochard L. Monitoring patient-ventilator asynchrony. Curr Opin Crit Care. 2016;22:246–53.
    1. Branson RD, Blakeman TC, Robinson BR. Asynchrony and dyspnea. Respir Care. 2013;58:973–89.
    1. Murias G, Lucangelo U, Blanch L. Patient-ventilator asynchrony. Curr Opin Crit Care. 2016;22:53–9.
    1. Pham T, Telias I, Piraino T, Yoshida T, Brochard LJ. Asynchrony consequences and management. Crit Care Clin. 2018;34:325–41.
    1. Tobin MJ, Jubran A, Laghi F. Patient-ventilator interaction. Am J Respir Crit Care Med. 2001;163:1059–63.
    1. Murias G, Villagra A, Blanch L. Patient-ventilator dyssynchrony during assisted invasive mechanical ventilation. Minerva Anestesiol. 2013;79:434–44.
    1. Epstein SK. How often does patient-ventilator asynchrony occur and what are the consequences? Respir Care. 2011;56:25–38.
    1. Sassoon CS. Triggering of the ventilator in patient-ventilator interactions. Respir Care. 2011;56:39–51.
    1. Delisle S, Charbonney E, Albert M, Ouellet P, Marsolais P, Rigollot M, et al. Patient-ventilator asynchrony due to reverse triggering occurring in brain-dead patients: clinical implications and physiological meaning. Am J Respir Crit Care Med. 2016;194:1166–8.
    1. Akoumianaki E, Lyazidi A, Rey N, Matamis D, Perez-Martinez N, Giraud R, et al. Mechanical ventilation-induced reverse-triggered breaths: A frequently unrecognized form of neuromechanical coupling. Chest. 2013;143:927–38.
    1. Nilsestuen JO, Hargett KD. Using ventilator graphics to identify patient-ventilator asynchrony. Respir Care. 2005;50:202–34.
    1. Kondili E, Xirouchaki N, Georgopoulos D. Modulation and treatment of patient-ventilator dyssynchrony. Curr Opin Crit Care. 2007;13:84–9.
    1. Hess DR. Ventilator waveforms and the physiology of pressure support ventilation. Respir Care. 2005;50:166–86.
    1. Georgopoulos D, Prinianakis G, Kondili E. Bedside waveforms interpretation as a tool to identify patient-ventilator asynchronies. Intensive Care Med. 2006;32:34–47.
    1. Colombo D, Cammarota G, Alemani M, Carenzo L, Barra FL, Vaschetto R, et al. Efficacy of ventilator waveforms observation in detecting patient-ventilator asynchrony. Crit Care Med. 2011;39:2452–7.
    1. Ramirez II, Arellano DH, Adasme RS, Landeros JM, Salinas FA, Vargas AG, et al. Ability of ICU health-care professionals to identify patient-ventilator asynchrony using waveform analysis. Respir Care. 2017;62:144–9.
    1. Chacón E, Estruga A, Murias G, Sales B, Montanya J, Lucangelo U, et al. Nurses' detection of ineffective inspiratory efforts during mechanical ventilation. Am J Crit Care. 2012;21:e89–93.
    1. Gutierrez G, Ballarino GJ, Turkan H, Abril J, de La Cruz L, Edsall C, et al. Automatic detection of patient-ventilator asynchrony by spectral analysis of airway flow. Crit Care. 2011;15:R167.
    1. Blanch L, Sales B, Montanya J, Lucangelo U, Garcia-Esquirol O, Villagra A, et al. Validation of the Better Care® system to detect ineffective efforts during expiration in mechanically ventilated patients: A pilot study. Intensive Care Med. 2012;38:772–80.
    1. Blanch L, Villagra A, Sales B, Montanya J, Lucangelo U, Luján M, et al. Asynchronies during mechanical ventilation are associated with mortality. Intensive Care Med. 2015;41:633–41.
    1. Gholami B, Phan TS, Haddad WM, Cason A, Mullis J, Price L, et al. Replicating human expertise of mechanical ventilation waveform analysis in detecting patient-ventilator cycling asynchrony using machine learning. Comput Biol Med. 2018;97:137–44.
    1. Mulqueeny Q, Redmond SJ, Tassaux D, Vignaux L, Jolliet P, Ceriana P, et al. Automated detection of asynchrony in patient-ventilator interaction. Conf Proc IEEE Eng Med Biol Soc. 2009;2009:5324–7.
    1. Sottile PD, Albers D, Higgins C, Mckeehan J, Moss MM. The association between ventilator dyssynchrony, delivered tidal volume, and sedation using a novel automated ventilator dyssynchrony detection algorithm. Crit Care Med. 2018;46:e151–7.
    1. Rolland-Debord C, Bureau C, Poitou T, Belin L, Clavel M, Perbet S, et al. Prevalence and prognosis impact of patient-ventilator asynchrony in early phase of weaning according to two detection methods. Anesthesiology. 2017;127:989–97.
    1. Thille AW, Rodriguez P, Cabello B, Lellouche F, Brochard L. Patient-ventilator asynchrony during assisted mechanical ventilation. Intensive Care Med. 2006;32:1515–22.
    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;24:74–80.
    1. Mellott KG, Grap MJ, Munro CL, Sessler CN, Wetzel PA, Nilsestuen JO, et al. Patient ventilator asynchrony in critically ill adults: Frequency and types. Heart Lung. 2014;43:231–43.
    1. Fabry B, Guttmann J, Eberhard L, Bauer T, Haberthür C, Wolff G. An analysis of desynchronization between the spontaneously breathing patient and ventilator during inspiratory pressure support. Chest. 1995;107:1387–94.
    1. Pohlman MC, McCallister KE, Schweickert WD, Pohlman AS, Nigos CP, Krishnan JA, et al. Excessive tidal volume from breath stacking during lung-protective ventilation for acute lung injury. Crit Care Med. 2008;36:3019–23.
    1. Mellott KG, Grap MJ, Munro CL, Sessler CN, Wetzel PA. Patient-ventilator dyssynchrony: Clinical significance and implications for practice. Crit Care Nurse. 2009;29:41–55. quiz 1 P following 55.
    1. Beitler JR, Sands SA, Loring SH, Owens RL, Malhotra A, Spragg RG, et al. Quantifying unintended exposure to high tidal volumes from breath stacking dyssynchrony in ARDS: The BREATHE criteria. Intensive Care Med. 2016;42:1427–36.
    1. Yoshida T, Fujino Y, Amato MB, Kavanagh BP. Fifty years of research in ARDS. Spontaneous breathing during mechanical ventilation. Risks, mechanisms, and management. Am J Respir Crit Care Med. 2017;195:985–92.
    1. Yoshida T, Nakahashi S, Nakamura MA, Koyama Y, Roldan R, Torsani V, et al. Volume-controlled ventilation does not prevent injurious inflation during spontaneous effort. Am J Respir Crit Care Med. 2017;196:590–601.
    1. Yoshida T, Amato MB, Kavanagh BP. Understanding spontaneous vs. ventilator breaths: Impact and monitoring. Intensive Care Med. 2018;44:2235–8.
    1. Yoshida T, Uchiyama A, Matsuura N, Mashimo T, Fujino Y. Spontaneous breathing during lung-protective ventilation in an experimental acute lung injury model: High transpulmonary pressure associated with strong spontaneous breathing effort may worsen lung injury. Crit Care Med. 2012;40:1578–85.
    1. Yoshida T, Torsani V, Gomes S, de Santis RR, Beraldo MA, Costa EL, et al. Spontaneous effort causes occult pendelluft during mechanical ventilation. Am J Respir Crit Care Med. 2013;188:1420–7.
    1. Yoshida T, Roldan R, Beraldo MA, Torsani V, Gomes S, de Santis RR, et al. Spontaneous effort during mechanical ventilation: Maximal injury with less positive end-expiratory pressure. Crit Care Med. 2016;44:e678–88.
    1. Yoshida T, Nakamura MA, Morais CC, Amato MB, Kavanagh BP. Reverse triggering causes an injurious inflation pattern during mechanical ventilation. Am J Respir Crit Care Med. 2018;198:1096–9.
    1. Kallet RH, Alonso JA, Luce JM, Matthay MA. Exacerbation of acute pulmonary edema during assisted mechanical ventilation using a low-tidal volume, lung-protective ventilator strategy. Chest. 1999;116:1826–32.
    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;37:2740–5.
    1. Gogineni VK, Brimeyer R, Modrykamien A. Patterns of patient-ventilator asynchrony as predictors of prolonged mechanical ventilation. Anaesth Intensive Care. 2012;40:964–70.
    1. Chanques G, Kress JP, Pohlman A, Patel S, Poston J, Jaber S, et al. Impact of ventilator adjustment and sedation-analgesia practices on severe asynchrony in patients ventilated in assist-control mode. Crit Care Med. 2013;41:2177–87.
    1. MacIntyre NR, McConnell R, Cheng KC, Sane A. Patient-ventilator flow dyssynchrony: Flow-limited versus pressure-limited breaths. Crit Care Med. 1997;25:1671–7.
    1. MacIntyre NR. Patient-ventilator interactions: Optimizing conventional ventilation modes. Respir Care. 2011;56:73–84.
    1. Thille AW, Cabello B, Galia F, Lyazidi A, Brochard L. Reduction of patient-ventilator asynchrony by reducing tidal volume during pressure-support ventilation. Intensive Care Med. 2008;34:1477–86.
    1. Figueroa-Casas JB, Montoya R. Effect of Tidal Volume Size and Its Delivery Mode on Patient-Ventilator Dyssynchrony. Ann Am Thorac Soc. 2016;13:2207–14.
    1. Gautam PL, Kaur G, Katyal S, Gupta R, Sandhu P, Gautam N. Comparison of patient-ventilator asynchrony during pressure support ventilation and proportional assist ventilation modes in surgical intensive care unit: A randomized crossover study. Indian J Crit Care Med. 2016;20:689–94.
    1. Vasconcelos RS, Sales RP, de Melo LH, Marinho LS, Pd Bastos V, da Nc Nogueira A, et al. Influences of duration of inspiratory effort, respiratory mechanics, and ventilator type on asynchrony with pressure support and proportional assist ventilation. Respir Care. 2017;62:550–7.
    1. Kress JP, Pohlman AS, O'Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342:1471–7.
    1. Sottile PD, Kiser TH, Burnham EL, Ho PM, Allen RR, Vandivier RW, et al. An observational study of the efficacy of cisatracurium compared with vecuronium in patients with or at risk for acute respiratory distress syndrome. Am J Respir Crit Care Med. 2018;197:897–904.
    1. Moss M, Ulysse CA, Angus DC. National Heart, Lung, and Blood Institute PETAL Clinical Trials Network. Early neuromuscular blockade in the acute respiratory distress syndrome. N Engl J Med. 2019;380:1997–2008.
    1. Unroe M, MacIntyre N. Evolving approaches to assessing and monitoring patient-ventilator interactions. Curr Opin Crit Care. 2010;16:261–8.
    1. Mellenthin MM, Seong SA, Roy GS, Bartolák-Suki E, Hamlington KL, Bates JH, et al. Using injury cost functions from a predictive single compartment model to assess the severity of mechanical ventilator induced lung injuries. J Appl Physiol. 2019;127:58–70.
    1. Hamlington KL, Smith BJ, Allen GB, Bates JH. Predicting ventilator-induced lung injury using a lung injury cost function. J Appl Physiol (1985) 2016;121:106–14.
    1. Hamlington KL, Smith BJ, Dunn CM, Charlebois CM, Roy GS, Bates JH. Linking lung function to structural damage of alveolar epithelium in ventilator-induced lung injury. Respir Physiol Neurobiol. 2018;255:22–9.
    1. Smith BJ, Grant KA, Bates JH. Linking the development of ventilator-induced injury to mechanical function in the lung. Ann Biomed Eng. 2013;41:527–36.
    1. Papazian L, Forel JM, Gacouin A, Penot-Ragon C, Perrin G, Loundou A, et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med. 2010;363:1107–16.

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