Proportional modes of ventilation: technology to assist physiology
Annemijn H Jonkman, Michela Rauseo, Guillaume Carteaux, Irene Telias, Michael C Sklar, Leo Heunks, Laurent J Brochard, Annemijn H Jonkman, Michela Rauseo, Guillaume Carteaux, Irene Telias, Michael C Sklar, Leo Heunks, Laurent J Brochard
Abstract
Proportional modes of ventilation assist the patient by adapting to his/her effort, which contrasts with all other modes. The two proportional modes are referred to as neurally adjusted ventilatory assist (NAVA) and proportional assist ventilation with load-adjustable gain factors (PAV+): they deliver inspiratory assist in proportion to the patient's effort, and hence directly respond to changes in ventilatory needs. Due to their working principles, NAVA and PAV+ have the ability to provide self-adjusted lung and diaphragm-protective ventilation. As these proportional modes differ from 'classical' modes such as pressure support ventilation (PSV), setting the inspiratory assist level is often puzzling for clinicians at the bedside as it is not based on usual parameters such as tidal volumes and PaCO2 targets. This paper provides an in-depth overview of the working principles of NAVA and PAV+ and the physiological differences with PSV. Understanding these differences is fundamental for applying any assisted mode at the bedside. We review different methods for setting inspiratory assist during NAVA and PAV+ , and (future) indices for monitoring of patient effort. Last, differences with automated modes are mentioned.
Keywords: Inspiratory assist; Mechanical ventilation; Proportional modes; Respiratory effort.
Conflict of interest statement
AHJ reports personal fees from Liberate Medical, outside the submitted work. GC reports personal fees from Air Liquide Medical System, personal fees from Löwenstein, outside the submitted work. LH has received grants from Orion Pharma and Liberate Medical and speakers fee from Getinge. LB conducts an investigator-initiated trial on PAV+ (NCT02447692) funded by the Canadian Institute for Health Research and a partnership with Medtronic Covidien; his laboratory also receives grants and non-financial support from Fisher & Paykel, non-financial support from Air Liquide Medical System, non-financial support from Philips, non-financial support from Sentec, other from General Electric. Other authors have nothing to declare.
Figures
References
- Vaporidi K. NAVA and PAV+ for lung and diaphragm protection. Curr Opin Crit Care. 2020;26:41–46. doi: 10.1097/MCC.0000000000000684.
- Younes M. Proportional assist ventilation, a new approach to ventilatory support: theory. Am Rev Respir Dis. 1992;145:114–120. doi: 10.1164/ajrccm/145.1.114.
- Sinderby C, Navalesi P, Beck J, et al. Neural control of mechanical ventilation in respiratory failure. Nat Med. 1999;5:1433–1436. doi: 10.1038/71012.
- Suarez-Sipmann F. New modes of assisted mechanical ventilation. Med Intensive Engl Ed. 2014;38:249–260. doi: 10.1016/j.medine.2014.04.001.
- Goligher EC, Fan E, Herridge MS, et al. Evolution of diaphragm thickness during mechanical ventilation impact of inspiratory effort. Am J Respir Crit Care Med. 2015;192:1080–1088. doi: 10.1164/rccm.201503-0620OC.
- Kondili E, Prinianakis G, Georgopoulos D. Patient-ventilator interaction. Br J Anaesth. 2003;91:106–119. doi: 10.1093/bja/aeg129.
- Leung P, Jubran A, Tobin MJ. Comparison of assisted ventilator modes on triggering, patient effort, and dyspnea. Am J Respir Crit Care Med. 1997;155:1940–1948. doi: 10.1164/ajrccm.155.6.9196100.
- Thille AW, Cabello B, Galia F, et al. Reduction of patient-ventilator asynchrony by reducing tidal volume during pressure-support ventilation. Intensive Care Med. 2008;34:1477–1486. doi: 10.1007/s00134-008-1121-9.
- Colombo D, Cammarota G, Alemani M, et al. Efficacy of ventilator waveforms observation in detecting patient–ventilator asynchrony. Crit Care Med. 2011;39:2452–2457. doi: 10.1097/CCM.0b013e318225753c.
- Younes M, Kun J, Masiowski B, et al. A method for noninvasive determination of inspiratory resistance during proportional assist ventilation. Am J Respir Crit Care Med. 2001;163:829–839. doi: 10.1164/ajrccm.163.4.2005063.
- Younes M, Webster K, Kun J, et al. A method for measuring passive elastance during proportional assist ventilation. Am J Respir Crit Care Med. 2001;164:50–60. doi: 10.1164/ajrccm.164.1.2010068.
- Xirouchaki N, Kondili E, Klimathianaki M, Georgopoulos D. Is proportional-assist ventilation with load-adjustable gain factors a user-friendly mode? Intensive Care Med. 2009;35:1599–1603. doi: 10.1007/s00134-009-1524-2.
- Terzi N, Piquilloud L, Rozé H, et al. Clinical review: update on neurally adjusted ventilatory assist - report of a round-table conference. Crit Care. 2012;16:225. doi: 10.1186/cc11297.
- Carteaux G, Mancebo J, Mercat A, et al. Bedside adjustment of proportional assist ventilation to target a predefined range of respiratory effort. Crit Care Med. 2013;41:2125–2132. doi: 10.1097/CCM.0b013e31828a42e5.
- Telias I, Brochard L, Goligher EC. Is my patient’s respiratory drive (too) high? Intensive Care Med. 2018;44:1936–1939. doi: 10.1007/s00134-018-5091-2.
- Yoshida T, Nakahashi S, Nakamura MAM, et al. Volume-controlled ventilation does not prevent injurious inflation during spontaneous effort. Am J Respir Crit Care Med. 2017;196:590–601. doi: 10.1164/rccm.201610-1972OC.
- Jonkman AH, de Vries HJ, Heunks LMA. Physiology of the respiratory drive in icu patients: implications for diagnosis and treatment. Crit Care. 2020;24:104. doi: 10.1186/s13054-020-2776-z.
- Demoule A, Clavel M, Rolland-Debord C, et al. Neurally adjusted ventilatory assist as an alternative to pressure support ventilation in adults: a French multicentre randomized trial. Intensive Care Med. 2016;42:1723–1732. doi: 10.1007/s00134-016-4447-8.
- Kataoka J, Kuriyama A, Norisue Y, Fujitani S. Proportional modes versus pressure support ventilation: a systematic review and meta-analysis. Ann Intensive Care. 2018;8:123. doi: 10.1186/s13613-018-0470-y.
- Liu L, Xu X, Sun Q, et al (2020) Neurally adjusted ventilatory assist versus pressure support ventilation in diffiult weaning. Anesthesiology 1482–93
- Hadfield DJ, Rose L, Reid F, et al. Neurally adjusted ventilatory assist versus pressure support ventilation: a randomized controlled feasibility trial performed in patients at risk of prolonged mechanical ventilation. Crit Care. 2020;24:220. doi: 10.1186/s13054-020-02923-5.
- Esteban A, Ferguson ND, Meade MO, et al. Evolution of mechanical ventilation in response to clinical research. Am J Respir Crit Care Med. 2008;177:170–177. doi: 10.1164/rccm.200706-893OC.
- Tobin MJ, Gardner W. Principles and practice of intensive care monitoring. New York: McGraw-Hill; 1998. Monitoring the control of breathing; pp. 415–464.
- Telias I, Spadaro S. Techniques to monitor respiratory drive and inspiratory effort. Curr Opin Crit Care. 2020;26:3–10. doi: 10.1097/MCC.0000000000000680.
- Beck J, Gottfried SB, Navalesi P, et al. Electrical activity of the diaphragm during pressure support ventilation in acute respiratory failure. Am J Respir Crit Care Med. 2001;164:419–424. doi: 10.1164/ajrccm.164.3.2009018.
- Bellani G, Mauri T, Coppadoro A, et al. Estimation of patient’s inspiratory effort from the electrical activity of the diaphragm. Crit Care Med. 2013;41:1483–1491. doi: 10.1097/CCM.0b013e31827caba0.
- Sinderby C, Beck J, Spahija J, et al. Inspiratory muscle unloading by neurally adjusted ventilatory assist during maximal inspiratory efforts in healthy subjects. Chest. 2007;131:711–717. doi: 10.1378/chest.06-1909.
- Spinelli E, Mauri T, Beitler JR, et al. Respiratory drive in the acute respiratory distress syndrome: pathophysiology, monitoring, and therapeutic interventions. Intensive Care Med. 2020;46:606–618. doi: 10.1007/s00134-020-05942-6.
- Tang G-J, Kou YR, Lin YS (1998) Peripheral neural modulation of endotoxin-induced hyperventilation. Crit Care Med 26
- Jacono FJ, Mayer CA, Hsieh Y-H, et al. Lung and brainstem cytokine levels are associated with breathing pattern changes in a rodent model of acute lung injury. Respir Physiol Neurobiol. 2011;178:429–438. doi: 10.1016/j.resp.2011.04.022.
- Lilitsis E, Stamatopoulou V, Andrianakis E, et al. Inspiratory effort and breathing pattern change in response to varying the assist level: a physiological study. Respir Physiol Neurobiol. 2020 doi: 10.1016/j.resp.2020.103474.
- Kacmarek RM. Proportional assist ventilation and neurally adjusted ventilatory assist. Respir Care. 2011;56:140–152. doi: 10.4187/respcare.01021.
- Georgopoulos D, Mitrouska I, Webster K, et al. Effects of inspiratory muscle unloading on the response of respiratory motor output to CO2. Am J Respir Crit Care Med. 1997;155:2000–2009. doi: 10.1164/ajrccm.155.6.9196108.
- Georgopoulos D, Mitrouska I, Bshouty Z, et al. Respiratory response to co2 during pressure-support ventilation in conscious normal humans. Am J Respir Crit Care Med. 1997;156:146–154. doi: 10.1164/ajrccm.156.1.9606055.
- Vaporidi K, Akoumianaki E, Telias I, et al. Respiratory drive in critically ill patients. Pathophysiology and clinical implications. Am J Respir Crit Care Med. 2020;201:20–32. doi: 10.1164/rccm.201903-0596SO.
- Mitrouska J, Xirouchaki N, Patakas D, et al. Effects of chemical feedback on respiratory motor and ventilatory output during different modes of assisted mechanical ventilation. Eur Respir J. 1999;13:873. doi: 10.1034/j.1399-3003.1999.13d30.x.
- Brochard L, Harf A, Lorino H, Lemaire F. Inspiratory pressure support prevents diaphragmatic fatigue during weaning from mechanical ventilation. Am Rev Respir Dis. 1989;139:513–521. doi: 10.1164/ajrccm/139.2.513.
- Carteaux G, Córdoba-Izquierdo A, Lyazidi A, et al. Comparison between neurally adjusted ventilatory assist and pressure support ventilation levels in terms of respiratory effort. Crit Care Med. 2016;44:503–511. doi: 10.1097/CCM.0000000000001418.
- Parthasarathy S, Tobin MJ. Effect of ventilator mode on sleep quality in critically ill patients. Am J Respir Crit Care Med. 2002;166:1423–1429. doi: 10.1164/rccm.200209-999OC.
- Marini JJ, Rodriguez RM, Lamb V. The Inspiratory workload of patient-initiated mechanical ventilation. Am Rev Respir Dis. 1986;134:902–909. doi: 10.1164/arrd.1986.134.5.902.
- Doorduin J, Sinderby C, Beck J, et al. Assisted ventilation in patients with acute respiratory distress syndrome: lung-distending pressure and patient-ventilator interaction. Anesthesiology. 2015 doi: 10.1183/13993003.congress-2015.OA4478.
- Patroniti N, Bellani G, Saccavino E, et al. Respiratory pattern during neurally adjusted ventilatory assist in acute respiratory failure patients. Intensive Care Med. 2012;38:230–239. doi: 10.1007/s00134-011-2433-8.
- Spahija J, de Marchie M, Albert M, et al. Patient-ventilator interaction during pressure support ventilation and neurally adjusted ventilatory assist. Crit Care Med. 2010;38:518–526. doi: 10.1097/CCM.0b013e3181cb0d7b.
- Jonkman AH, Roesthuis LH, de Boer EC, et al. Inadequate assessment of patient-ventilator interaction due to suboptimal diaphragm electrical activity signal filtering. Am J Respir Crit Care Med. 2020;202:141–144. doi: 10.1164/rccm.201912-2306LE.
- Cecchini J, Schmidt M, Demoule A, Similowski T. Increased diaphragmatic contribution to inspiratory effort during neurally adjusted ventilatory assistance versus pressure support: an electromyographic study. Anesthesiology. 2014;121:1028–1036. doi: 10.1097/ALN.0000000000000432.
- Blankman P, Hasan D, van Mourik MS, Gommers D. Ventilation distribution measured with EIT at varying levels of pressure support and neurally adjusted ventilatory assist in patients with ALI. Intensive Care Med. 2013;39:1057–1062. doi: 10.1007/s00134-013-2898-8.
- Di Mussi R, Spadaro S, Mirabella L, et al. Impact of prolonged assisted ventilation on diaphragmatic efficiency: NAVA versus PSV. Crit Care. 2015;20:1. doi: 10.1186/s13054-015-1178-0.
- Costa R, Spinazzola G, Cipriani F, et al. A physiologic comparison of proportional assist ventilation with load-adjustable gain factors (PAV+) versus pressure support ventilation (PSV) Intensive Care Med. 2011;37:1494–1500. doi: 10.1007/s00134-011-2297-y.
- Kondili E, Prinianakis G, Alexopoulou C, et al. Respiratory load compensation during mechanical ventilation: proportional assist ventilation with load-adjustable gain factors versus pressure support. Intensive Care Med. 2006;32:692–699. doi: 10.1007/s00134-006-0110-0.
- Akoumianaki E, Prinianakis G, Kondili E, et al. Physiologic comparison of neurally adjusted ventilator assist, proportional assist and pressure support ventilation in critically ill patients. Respir Physiol Neurobiol. 2014;203:82–89. doi: 10.1016/j.resp.2014.08.012.
- Wrigge H, Golisch W, Zinserling J, et al. Proportional assist versus pressure support ventilation: effects on breathing pattern and respiratory work of patients with chronic obstructive pulmonary disease. Intensive Care Med. 1999;25:790–798. doi: 10.1007/s001340050954.
- Piquilloud L, Vignaux L, Bialais E, et al. Neurally adjusted ventilatory assist improves patient–ventilator interaction. Intensive Care Med. 2011;37:263–271. doi: 10.1007/s00134-010-2052-9.
- Schmidt M, Kindler F, Cecchini J, et al. Neurally adjusted ventilatory assist and proportional assist ventilation both improve patient-ventilator interaction. Crit Care. 2015;19:56. doi: 10.1186/s13054-015-0763-6.
- Lecomte F, Brander L, Jalde F, et al. Physiological response to increasing levels of neurally adjusted ventilatory assist (NAVA) Respir Physiol Neurobiol. 2009;166:117–124. doi: 10.1016/j.resp.2009.02.015.
- Leiter JC, Manning HL. The Hering-Breuer reflex, feedback control, and mechanical ventilation: the promise of neurally adjusted ventilatory assist. Crit Care Med. 2010;38:1915–1916. doi: 10.1097/CCM.0b013e3181ee4039.
- Smith J, Bellemare F. Effect of lung volume on in vivo contraction characteristics of human diaphragm. J Appl Physiol. 1987;62:1893–1900. doi: 10.1152/jappl.1987.62.5.1893.
- Vaporidi K, Psarologakis C, Proklou A, et al. Driving pressure during proportional assist ventilation: an observational study. Ann Intensive Care. 2019;9:1. doi: 10.1186/s13613-018-0477-4.
- Xirouchaki N, Kondili E, Vaporidi K, et al. Proportional assist ventilation with load-adjustable gain factors in critically ill patients: comparison with pressure support. Intensive Care Med. 2008;34:2026–2034. doi: 10.1007/s00134-008-1209-2.
- Bosma KJ, Read BA, Bahrgard Nikoo MJ, et al. A pilot randomized trial comparing weaning from mechanical ventilation on pressure support versus proportional assist ventilation. Crit Care Med. 2016;44:1098–1108. doi: 10.1097/CCM.0000000000001600.
- Bosma K, Ferreyra G, Ambrogio C, et al. Patient-ventilator interaction and sleep in mechanically ventilated patients: pressure support versus proportional assist ventilation. Crit Care Med. 2007;35:1048–1054. doi: 10.1097/01.CCM.0000260055.64235.7C.
- Delisle S, Ouellet P, Bellemare P, et al. Sleep quality in mechanically ventilated patients: comparison between NAVA and PSV modes. Ann Intensive Care. 2011;1:42. doi: 10.1186/2110-5820-1-42.
- Alexopoulou C, Kondili E, Plataki M, Georgopoulos D. Patient–ventilator synchrony and sleep quality with proportional assist and pressure support ventilation. Intensive Care Med. 2013;39:1040–1047. doi: 10.1007/s00134-013-2850-y.
- Fernández-Vivas M, Caturla-Such J, de la Rosa JG, et al. Noninvasive pressure support versus proportional assist ventilation in acute respiratory failure. Intensive Care Med. 2003;29:1126–1133. doi: 10.1007/s00134-003-1768-1.
- de la Oliva P, Schüffelmann C, Gómez-Zamora A, et al. Asynchrony, neural drive, ventilatory variability and COMFORT: NAVA versus pressure support in pediatric patients. A non-randomized cross-over trial. Intensive Care Med. 2012;38:838–846. doi: 10.1007/s00134-012-2535-y.
- Sinderby C, Beck J. Neurally adjusted ventilatory assist. In: Martin JT, editor. Principles and practice of mechanical ventilation. 3. New York: McGraw-Hill; 2013. pp. 351–375.
- Coisel Y, Chanques G, Jung B, et al. Neurally adjusted ventilatory assist in critically ill postoperative patients: a crossover randomized study. Anesthesiology. 2010;113:925–935. doi: 10.1097/ALN.0b013e3181ee2ef1.
- Brander L, Leong-Poi H, Beck J, et al. Titration and implementation of neurally adjusted ventilatory assist in critically ill patients. Chest. 2009;135:695–703. doi: 10.1378/chest.08-1747.
- Barwing J, Linden N, Ambold M, et al. Neurally adjusted ventilatory assist vs. pressure support ventilation in critically ill patients: an observational study. Acta Anaesthesiol Scand. 2011;55:1261–1271. doi: 10.1111/j.1399-6576.2011.02522.x.
- Rozé H, Lafrikh A, Perrier V, et al. Daily titration of neurally adjusted ventilatory assist using the diaphragm electrical activity. Intensive Care Med. 2011;37:1087–1094. doi: 10.1007/s00134-011-2209-1.
- Bertoni M, Telias I, Urner M, et al. A novel non-invasive method to detect excessively high respiratory effort and dynamic transpulmonary driving pressure during mechanical ventilation. Crit Care. 2019;23:346. doi: 10.1186/s13054-019-2617-0.
- Campoccia Jalde F, Jalde F, Wallin MKEB, et al. Standardized unloading of respiratory muscles during neurally adjusted ventilatory assist: a randomized crossover pilot study. Anesthesiology. 2018;129:769–777. doi: 10.1097/ALN.0000000000002335.
- Cammarota G, Longhini F, Perucca R, et al. New setting of neurally adjusted ventilatory assist during noninvasive ventilation through a helmet. Anesthesiology. 2016;125:1181–1189. doi: 10.1097/ALN.0000000000001354.
- Liu L, Xia F, Yang Y, et al. Neural versus pneumatic control of pressure support in patients with chronic obstructive pulmonary diseases at different levels of positive end expiratory pressure: a physiological study. Crit Care. 2015;19:244. doi: 10.1186/s13054-015-0971-0.
- Beloncle F, Piquilloud L, Rittayamai N, et al. A diaphragmatic electrical activity-based optimization strategy during pressure support ventilation improves synchronization but does not impact work of breathing. Crit Care. 2017;21:21. doi: 10.1186/s13054-017-1599-z.
- Grasselli G, Beck J, Mirabella L, et al. Assessment of patient–ventilator breath contribution during neurally adjusted ventilatory assist. Intensive Care Med. 2012;38:1224–1232. doi: 10.1007/s00134-012-2588-y.
- Jonkman AH, Jansen D, Gadgil S, et al. Monitoring patient-ventilator breath contribution in the critically ill during neurally adjusted ventilatory assist: reliability and improved algorithms for bedside use. J Appl Physiol. 2019;127:264–271. doi: 10.1152/japplphysiol.00071.2019.
- Jansen D, Jonkman AH, Roesthuis L, et al. Estimation of the diaphragm neuromuscular efficiency index in mechanically ventilated critically ill patients. Crit Care. 2018;22:238. doi: 10.1186/s13054-018-2172-0.
- Coppadoro A, Rona R, Bellani G, Foti G. A brief airway occlusion is sufficient to measure the patient’s inspiratory effort/electrical activity of the diaphragm index (PEI) J Clin Monit Comput. 2020 doi: 10.1007/s10877-020-00459-1.
- Beloncle F, Akoumianaki E, Rittayamai N, et al. Accuracy of delivered airway pressure and work of breathing estimation during proportional assist ventilation: a bench study. Ann Intensive Care. 2016;6:30. doi: 10.1186/s13613-016-0131-y.
- van der Staay M, Chatburn RL. Advanced modes of mechanical ventilation and optimal targeting schemes. Intensive Care Med Exp. 2018;6:30. doi: 10.1186/s40635-018-0195-0.
- Arnal J-M, Wysocki M, Novotni D, et al. Safety and efficacy of a fully closed-loop control ventilation (IntelliVent-ASV®) in sedated ICU patients with acute respiratory failure: a prospective randomized crossover study. Intensive Care Med. 2012;38:781–787. doi: 10.1007/s00134-012-2548-6.
- Otis AB, Fenn WO, Rahn H. Mechanics of breathing in man. J Appl Physiol. 1950;2:592–607. doi: 10.1152/jappl.1950.2.11.592.
- Mead J. Control of respiratory frequency. J Appl Physiol. 1960;15:325–336. doi: 10.1152/jappl.1960.15.3.325.
- Sulemanji D, Marchese A, Garbarini P, et al. Adaptive support ventilation: an appropriate mechanical ventilation strategy for acute respiratory distress syndrome? Anesthesiology. 2009;111:863–870. doi: 10.1097/ALN.0b013e3181b55f8f.
- Dongelmans DA, Veelo DP, Bindels A, et al. Determinants of tidal volumes with adaptive support ventilation: a multicenter observational study. Anesth Analg. 2008;107:932–937. doi: 10.1213/ane.0b013e31817f1dcf.
- Dongelmans DA, Paulus F, Veelo DP, et al. Adaptive support ventilation may deliver unwanted respiratory rate–tidal volume combinations in patients with acute lung injury ventilated according to an open lung concept. Anesthesiology. 2011;114:1138–1143. doi: 10.1097/ALN.0b013e31820d8676.
- Gruber PC, Gomersall CD, Leung P, et al. Randomized controlled trial comparing adaptive-support ventilation with pressure-regulated volume-controlled ventilation with automode in weaning patients after cardiac surgery. Anesthesiology. 2008;109:81–87. doi: 10.1097/ALN.0b013e31817881fc.
- Chen C-W, Wu C-P, Dai Y-L, et al. Effects of implementing adaptive support ventilation in a medical intensive care unit. Respir Care. 2011;56:976–983. doi: 10.4187/respcare.00966.
- Arnal J-M, Garnero A, Novonti D, et al. Feasibility study on full closed-loop control ventilation (IntelliVent-ASV™) in ICU patients with acute respiratory failure: a prospective observational comparative study. Crit Care. 2013;17:R196. doi: 10.1186/cc12890.
- Lellouche F, Mancebo J, Jolliet P, et al. A multicenter randomized trial of computer-driven protocolized weaning from mechanical ventilation. Am J Respir Crit Care Med. 2006;174:894–900. doi: 10.1164/rccm.200511-1780OC.
- Dojat M, Brochard L, Lemaire F, Harf A. A knowledge-based system for assisted ventilation of patients in intensive care units. Int J Clin Monit Comput. 1992;9:239–250. doi: 10.1007/BF01133619.
- Burns KE, Lellouche F, Nisenbaum R, et al. Automated weaning and SBT systems versus non-automated weaning strategies for weaning time in invasively ventilated critically ill adults. Cochrane Database Syst Rev. 2014 doi: 10.1002/14651858.CD008638.pub2.
- Lellouche F, Brochard L. Advanced closed loops during mechanical ventilation (PAV, NAVA, ASV, SmartCare) Best Pract Res Clin Anaesthesiol. 2009;23:81–93. doi: 10.1016/j.bpa.2008.08.001.
Source: PubMed