Continuous assessment of neuro-ventilatory drive during 12 h of pressure support ventilation in critically ill patients

Rosa Di Mussi, Savino Spadaro, Carlo Alberto Volta, Nicola Bartolomeo, Paolo Trerotoli, Francesco Staffieri, Luigi Pisani, Rachele Iannuzziello, Lidia Dalfino, Francesco Murgolo, Salvatore Grasso, Rosa Di Mussi, Savino Spadaro, Carlo Alberto Volta, Nicola Bartolomeo, Paolo Trerotoli, Francesco Staffieri, Luigi Pisani, Rachele Iannuzziello, Lidia Dalfino, Francesco Murgolo, Salvatore Grasso

Abstract

Introduction: Pressure support ventilation (PSV) should allow spontaneous breathing with a "normal" neuro-ventilatory drive. Low neuro-ventilatory drive puts the patient at risk of diaphragmatic atrophy while high neuro-ventilatory drive may causes dyspnea and patient self-inflicted lung injury. We continuously assessed for 12 h the electrical activity of the diaphragm (EAdi), a close surrogate of neuro-ventilatory drive, during PSV. Our aim was to document the EAdi trend and the occurrence of periods of "Low" and/or "High" neuro-ventilatory drive during clinical application of PSV.

Method: In 16 critically ill patients ventilated in the PSV mode for clinical reasons, inspiratory peak EAdi peak (EAdiPEAK), pressure time product of the trans-diaphragmatic pressure per breath and per minute (PTPDI/b and PTPDI/min, respectively), breathing pattern and major asynchronies were continuously monitored for 12 h (from 8 a.m. to 8 p.m.). We identified breaths with "Normal" (EAdiPEAK 5-15 μV), "Low" (EAdiPEAK < 5 μV) and "High" (EAdiPEAK > 15 μV) neuro-ventilatory drive.

Results: Within all the analyzed breaths (177.117), the neuro-ventilatory drive, as expressed by the EAdiPEAK, was "Low" in 50.116 breath (28%), "Normal" in 88.419 breaths (50%) and "High" in 38.582 breaths (22%). The average times spent in "Low", "Normal" and "High" class were 1.37, 3.67 and 0.55 h, respectively (p < 0.0001), with wide variations among patients. Eleven patients remained in the "Low" neuro-ventilatory drive class for more than 1 h, median 6.1 [3.9-8.5] h and 6 in the "High" neuro-ventilatory drive class, median 3.4 [2.2-7.8] h. The asynchrony index was significantly higher in the "Low" neuro-ventilatory class, mainly because of a higher number of missed efforts.

Conclusions: We observed wide variations in EAdi amplitude and unevenly distributed "Low" and "High" neuro ventilatory drive periods during 12 h of PSV in critically ill patients. Further studies are needed to assess the possible clinical implications of our physiological findings.

Keywords: Assisted modes of ventilation; Mechanical ventilation; Pressure support ventilation (PSV).

Conflict of interest statement

Salvatore Grasso in the past 2 years received fees for lectures and board membership from: Getinge Critical Care (Solna SW), Estor Critical Care (Pero, Milan Italy). The other authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Flow diagram of patient’s enrollment. NG = naso-gastric; EAdi = electric diaphragmatic activity
Fig. 2
Fig. 2
Percentage of the collected breaths (including all the patients and the whole study period) belonging to the “Low” (28%), “Normal” (50%) and “High” (22%) neuro-ventilatory drive class (chi-square = 45; p = 0.0001)
Fig. 3
Fig. 3
Individual neuro-ventilatory drive trend throughout the study. Each point represents the electric diaphragmatic activity peak (EAdiPEAK) of a single breath. The two red lines represent the 5–15 μV EAdiPEAK range depicting the “Normal” neuro-ventilatory drive
Fig. 4
Fig. 4
Individual percentage of study time in which each patient remained in the “Low”, “Normal” and “High” neuro-ventilatory drive class. Eleven patients remained in the “Low” neuro-ventilatory drive class for more than one hour, median 6.1 [3.9–8.5] h. Six patients remained in the “High” neuro-ventilatory drive class for more than one hour, median 3.4 [2.2–7.8] h
Fig. 5
Fig. 5
According to the multivariable multinomial logistic model, the risk of being in the “High” neuro-ventilatory drive class increased exponentially with respiratory rate (RR, Left Panel) and tidal volume/predicted body weight (VT/PBW, Right Panel)

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