Patient-ventilator asynchrony in acute brain-injured patients: a prospective observational study

Xu-Ying Luo, Xuan He, Yi-Min Zhou, Yu-Mei Wang, Jing-Ran Chen, Guang-Qiang Chen, Hong-Liang Li, Yan-Lin Yang, Linlin Zhang, Jian-Xin Zhou, Xu-Ying Luo, Xuan He, Yi-Min Zhou, Yu-Mei Wang, Jing-Ran Chen, Guang-Qiang Chen, Hong-Liang Li, Yan-Lin Yang, Linlin Zhang, Jian-Xin Zhou

Abstract

Background: Patient-ventilator asynchrony is common in mechanically ventilated patients and may be related to adverse outcomes. Few studies have reported the occurrence of asynchrony in brain-injured patients. We aimed to investigate the prevalence, type and severity of patient-ventilator asynchrony in mechanically ventilated patients with brain injury.

Methods: This prospective observational study enrolled acute brain-injured patients undergoing mechanical ventilation. Esophageal pressure monitoring was established after enrollment. Flow, airway pressure, and esophageal pressure-time waveforms were recorded for a 15-min interval, four times daily for 3 days, for visually detecting asynchrony by offline analysis. At the end of each dataset recording, the respiratory drive was determined by the airway occlusion maneuver. The asynchrony index was calculated to represent the severity. The relationship between the prevalence and the severity of asynchrony with ventilatory modes and settings, respiratory drive, and analgesia and sedation were determined. Association of severe patient-ventilator asynchrony, which was defined as an asynchrony index ≥ 10%, with clinical outcomes was analyzed.

Results: In 100 enrolled patients, a total of 1076 15-min waveform datasets covering 330,292 breaths were collected, in which 70,156 (38%) asynchronous breaths were detected. Asynchrony occurred in 96% of patients with the median (interquartile range) asynchrony index of 12.4% (4.3%-26.4%). The most prevalent type was ineffective triggering. No significant difference was found in either prevalence or asynchrony index among different classifications of brain injury (p > 0.05). The prevalence of asynchrony was significantly lower during pressure control/assist ventilation than during other ventilatory modes (p < 0.05). Compared to the datasets without asynchrony, the airway occlusion pressure was significantly lower in datasets with ineffective triggering (p < 0.001). The asynchrony index was significantly higher during the combined use of opioids and sedatives (p < 0.001). Significantly longer duration of ventilation and hospital length of stay after the inclusion were found in patients with severe ineffective triggering (p < 0.05).

Conclusions: Patient-ventilator asynchrony is common in brain-injured patients. The most prevalent type is ineffective triggering and its severity is likely related to a long duration of ventilation and hospital stay. Prevalence and severity of asynchrony are associated with ventilatory modes, respiratory drive and analgesia/sedation strategy, suggesting treatment adjustment in this particular population. Trial registration The study has been registered on 4 July 2017 in ClinicalTrials.gov (NCT03212482) ( https://ichgcp.net/clinical-trials-registry/NCT03212482 ).

Keywords: Asynchrony; Brain injury; Mechanical ventilation; Monitoring; Prevalence; Severity.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Patients flow-chart
Fig. 2
Fig. 2
The proportion of different types of patient–ventilator asynchrony in breath-based analysis. A total of 70,156 asynchronous breaths were detected
Fig. 3
Fig. 3
No significant difference was found in asynchrony index among the three classifications of brain injury (p = 0.128). Individual data, median, and interquartile ranges are shown. The median (interquartile range) asynchrony index was 13.5% (3.3%–35.3%), 9.5% (3.5%–20.6%), and 16.8% (11.7%–39.5%) in patients with stroke, post-craniotomy for brain tumor, and traumatic brain injury, respectively
Fig. 4
Fig. 4
A significant difference in the prevalence of asynchrony was found among different ventilatory modes (p < 0.001, panel a). Percentage and 95% confidence interval are shown. The prevalence of asynchrony during pressure assist/control ventilation (PACV) was significantly lower than those during pressure support ventilation (PSV), volume assist/control ventilation (VACV), and pressure-preset synchronized intermittent mandatory ventilation plus pressure support (SIMV + PS). No significant difference was found among the PSV, VACV, and SIMV + PS (panel b). Individual data, median, and interquartile ranges are shown. A significant difference in asynchrony index was also found among different ventilatory modes (p < 0.001, panel b). Asynchrony indexes during PACV and PSV were significantly lower than those during VACV and SIMV + PS
Fig. 5
Fig. 5
The airway occlusion pressure (P0.1) with different types of asynchrony. Individual data, median, and interquartile ranges are shown. Compared to the datasets without asynchrony, P0.1 was significantly lower in datasets with ineffective triggering (p < 0.001). Although there was a tendency in elevated P0.1 values in datasets with premature cycling and flow insufficiency, no statistical significances were found (p > 0.999)
Fig. 6
Fig. 6
A significant difference in the asynchrony index was found among different analgesia/sedation strategies (p < 0.001). Individual data, median, and interquartile ranges are shown. Asynchrony index during combined administration of opioids and sedatives was significantly higher than those during single use of opioids or sedatives, as well as no use of these two types of drugs. No significant difference was found in asynchrony index among the latter three conditions

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