Clinical risk factors for increased respiratory drive in intubated hypoxemic patients

Elena Spinelli, Antonio Pesenti, Douglas Slobod, Carla Fornari, Roberto Fumagalli, Giacomo Grasselli, Carlo Alberto Volta, Giuseppe Foti, Paolo Navalesi, Rihard Knafelj, Paolo Pelosi, Jordi Mancebo, Laurent Brochard, Tommaso Mauri, Elena Spinelli, Antonio Pesenti, Douglas Slobod, Carla Fornari, Roberto Fumagalli, Giacomo Grasselli, Carlo Alberto Volta, Giuseppe Foti, Paolo Navalesi, Rihard Knafelj, Paolo Pelosi, Jordi Mancebo, Laurent Brochard, Tommaso Mauri

Abstract

Background: There is very limited evidence identifying factors that increase respiratory drive in hypoxemic intubated patients. Most physiological determinants of respiratory drive cannot be directly assessed at the bedside (e.g., neural inputs from chemo- or mechano-receptors), but clinical risk factors commonly measured in intubated patients could be correlated with increased drive. We aimed to identify clinical risk factors independently associated with increased respiratory drive in intubated hypoxemic patients.

Methods: We analyzed the physiological dataset from a multicenter trial on intubated hypoxemic patients on pressure support (PS). Patients with simultaneous assessment of the inspiratory drop in airway pressure at 0.1-s during an occlusion (P0.1) and risk factors for increased respiratory drive on day 1 were included. We evaluated the independent correlation of the following clinical risk factors for increased drive with P0.1: severity of lung injury (unilateral vs. bilateral pulmonary infiltrates, PaO2/FiO2, ventilatory ratio); arterial blood gases (PaO2, PaCO2 and pHa); sedation (RASS score and drug type); SOFA score; arterial lactate; ventilation settings (PEEP, level of PS, addition of sigh breaths).

Results: Two-hundred seventeen patients were included. Clinical risk factors independently correlated with higher P0.1 were bilateral infiltrates (increase ratio [IR] 1.233, 95%CI 1.047-1.451, p = 0.012); lower PaO2/FiO2 (IR 0.998, 95%CI 0.997-0.999, p = 0.004); higher ventilatory ratio (IR 1.538, 95%CI 1.267-1.867, p < 0.001); lower pHa (IR 0.104, 95%CI 0.024-0.464, p = 0.003). Higher PEEP was correlated with lower P0.1 (IR 0.951, 95%CI 0.921-0.982, p = 0.002), while sedation depth and drugs were not associated with P0.1.

Conclusions: Independent clinical risk factors for higher respiratory drive in intubated hypoxemic patients include the extent of lung edema and of ventilation-perfusion mismatch, lower pHa, and lower PEEP, while sedation strategy does not affect drive. These data underline the multifactorial nature of increased respiratory drive.

Keywords: Acute respiratory failure; Positive end-expiratory pressure; Respiratory drive; Risk factors.

Conflict of interest statement

PN received personal fees for lectures from Fisher and Paykel, Mindray, Hamilton, outside of the submitted work. TM received personal fees for lectures from Drager, Mindray and Fisher and Paykel, outside of the submitted work. All other authors declare that they have no competing interests.

© 2023. The Author(s).

Figures

Fig. 1
Fig. 1
Association between severity of lung injury (ventilation/perfusion mismatch) and P0.1. Results of bivariate analyses show that P0.1 was inversely associated to PaO2/FiO2 and directly associated with ventilatory ratio, indicating that impairment in oxygenation and CO2 clearance are clinical risk factors for increased respiratory drive
Fig. 2
Fig. 2
Association between arterial blood gases and P0.1. Results of bivariate analyses show that P0.1 was inversely associated with both PaO2 and PaCO2, while the association with arterial pH was not statistically significant
Fig. 3
Fig. 3
Impact of sedation depth on P0.1. No significant association was found between P0.1 and RASS category at bivariate analysis
Fig. 4
Fig. 4
Impact of PEEP on P0.1. Clinically set PEEP was inversely associated with P0.1, indicating that lower PEEP is a risk factor for increased respiratory drive in these patients

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