Sigh maneuver to enhance assessment of fluid responsiveness during pressure support ventilation

Antonio Messina, Davide Colombo, Federico Lorenzo Barra, Gianmaria Cammarota, Giacomo De Mattei, Federico Longhini, Stefano Romagnoli, Francesco DellaCorte, Daniel De Backer, Maurizio Cecconi, Paolo Navalesi, Antonio Messina, Davide Colombo, Federico Lorenzo Barra, Gianmaria Cammarota, Giacomo De Mattei, Federico Longhini, Stefano Romagnoli, Francesco DellaCorte, Daniel De Backer, Maurizio Cecconi, Paolo Navalesi

Abstract

Background: Assessment of fluid responsiveness is problematic in intensive care unit (ICU) patients, in particular for those undergoing modes of partial support, such as pressure support ventilation (PSV). We propose a new test, based on application of a ventilator-generated sigh, to predict fluid responsiveness in ICU patients undergoing PSV.

Methods: This was a prospective bi-centric interventional study conducted in two general ICUs. In 40 critically ill patients with a stable ventilatory PSV pattern and requiring volume expansion (VE), we assessed the variations in arterial systolic pressure (SAP), pulse pressure (PP) and stroke volume index (SVI) consequent to random application of 4-s sighs at three different inspiratory pressures. A radial arterial signal was directed to the MOSTCARE™ pulse contour hemodynamic monitoring system for hemodynamic measurements. Data obtained during sigh tests were recorded beat by beat, while all the hemodynamic parameters were averaged over 30 s for the remaining period of the study protocol. VE consisted of 500 mL of crystalloids over 10 min. A patient was considered a responder if a VE-induced increase in cardiac index (CI) ≥ 15% was observed.

Results: The slopes for SAP, SVI and PP of were all significantly different between responders and non-responders (p < 0.0001, p = 0.0004 and p < 0.0001, respectively). The AUC of the slope of SAP (0.99; sensitivity 100.0% (79.4-100.0%) and specificity 95.8% (78.8-99.9%) was significantly greater than the AUC for PP (0.91) and SVI (0.83) (p = 0.04 and 0.009, respectively). The SAP slope best threshold value of the ROC curve was - 4.4° from baseline. The only parameter found to be independently associated with fluid responsiveness among those included in the logistic regression was the slope for SAP (p = 0.009; odds ratio 0.27 (95% confidence interval (CI95) 0.10-0.70)). The effects produced by the sigh at 35 cmH20 (Sigh35) are significantly different between responders and non-responders. For a 35% reduction in PP from baseline, the AUC was 0.91 (CI95 0.82-0.99), with sensitivity 75.0% and specificity 91.6%.

Conclusions: In a selected ICU population undergoing PSV, analysis of the slope for SAP after the application of three successive sighs and the nadir of PP after Sigh35 reliably predict fluid responsiveness.

Trial registration: Australian New Zealand Clinical Trials Registry, ACTRN12615001232527 . Registered on 10 November 2015.

Keywords: Fluid responsiveness; Functional hemodynamic assessment; Pressure support ventilation; Sigh maneuver.

Conflict of interest statement

Ethics approval and consent to participate

The study was performed in the ICUs of two University Hospitals (Novara and Florence) after approval of the institutional ethics committees, in accordance with the principles of the Declaration of Helsinki. Patient’s written consent was managed as indicated by the ethics committees.

Consent for publication

Not applicable.

Competing interests

Dr. Romagnoli received speaking fees and travel expenses for scientific meetings from Vygon. Dr. Messina received travel expenses for scientific meetings from Vygon.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Schematic illustration of pulse pressure (PP) and stroke volume index (SVI) variations after Sigh35 in one responder. The solid line with squares indicates PP and the dotted line with circles depicts SVI. Baseline_1 corresponds to the 20 heartbeats preceeding Sigh35, which starts at heartbeat number 20, as indicated by the dotted vertical line. Nadir values of PP and SVI are indicated by the larger square and circle, respectively. Both PP and SVI dropped after application of Sigh35
Fig. 2
Fig. 2
Slope calculation of responders (blue line) and non-responders (red line) of systolic arterial pressure (SAP). The blue triangles and the red circles represent the mean values of the two populations (responders and non-responders, respectively) at each step of the protocol. The AUC for the slope of SAP (0.99; sensitivity 100.0% (79.4–100.0%) and specificity 95.8% (78.8–99.9%)) was significantly greater than the AUCs for PP (0.91) and SVI (0.83) (p = 0.04 and 0.009, respectively). The SAP slope best threshold value of the ROC curve was − 4.4° from baseline

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