Neural control of pressure support ventilation improved patient-ventilator synchrony in patients with different respiratory system mechanical properties: a prospective, crossover trial

Ling Liu, Xiao-Ting Xu, Yue Yu, Qin Sun, Yi Yang, Hai-Bo Qiu, Ling Liu, Xiao-Ting Xu, Yue Yu, Qin Sun, Yi Yang, Hai-Bo Qiu

Abstract

Background: Conventional pressure support ventilation (PSP) is triggered and cycled off by pneumatic signals such as flow. Patient-ventilator asynchrony is common during pressure support ventilation, thereby contributing to an increased inspiratory effort. Using diaphragm electrical activity, neurally controlled pressure support (PSN) could hypothetically eliminate the asynchrony and reduce inspiratory effort. The purpose of this study was to compare the differences between PSN and PSP in terms of patient-ventilator synchrony, inspiratory effort, and breathing pattern.

Methods: Eight post-operative patients without respiratory system comorbidity, eight patients with acute respiratory distress syndrome (ARDS) and obvious restrictive acute respiratory failure (ARF), and eight patients with chronic obstructive pulmonary disease (COPD) and mixed restrictive and obstructive ARF were enrolled. Patient-ventilator interactions were analyzed with macro asynchronies (ineffective, double, and auto triggering), micro asynchronies (inspiratory trigger delay, premature, and late cycling), and the total asynchrony index (AI). Inspiratory efforts for triggering and total inspiration were analyzed.

Results: Total AI of PSN was consistently lower than that of PSP in COPD (3% vs. 93%, P = 0.012 for 100% support level; 8% vs. 104%, P = 0.012 for 150% support level), ARDS (8% vs. 29%, P = 0.012 for 100% support level; 16% vs. 41%, P = 0.017 for 150% support level), and post-operative patients (21% vs. 35%, P = 0.012 for 100% support level; 15% vs. 50%, P = 0.017 for 150% support level). Improved support levels from 100% to 150% statistically increased total AI during PSP but not during PSN in patients with COPD or ARDS. Patients' inspiratory efforts for triggering and total inspiration were significantly lower during PSN than during PSP in patients with COPD or ARDS under both support levels (P < 0.05). There was no difference in breathing patterns between PSN and PSP.

Conclusions: PSN improves patient-ventilator synchrony and generates a respiratory pattern similar to PSP independently of any level of support in patients with different respiratory system mechanical properties. PSN, which reduces the trigger and total patient's inspiratory effort in patients with COPD or ARDS, might be an alternative mode for PSP.

Trial registration: ClinicalTrials.gov, NCT01979627; https://ichgcp.net/clinical-trials-registry/NCT01979627.

Conflict of interest statement

Ling Liu and Hai-Bo Qiu received a grant from Mindray (China). The other authors declare no competing interests.

Copyright © 2021 The Chinese Medical Association, produced by Wolters Kluwer, Inc. under the CC-BY-NC-ND license.

Figures

Figure 1
Figure 1
Total asynchrony index during PSP and PSN. Boxplot graphs showing the group values of the median (interquartile range) and 95% confidence interval for the total asynchrony index. Compared between support levels of 100% and 150% in the same mode, aP < 0.05. ARDS: Acute respiratory distress syndrome; COPD: Chronic obstructive pulmonary disease; PSN: controlled pressure support ventilation; PSP: Conventional pressure support ventilation.
Figure 2
Figure 2
Cycling-off error and trigger error during PSP and PSN. (A) Cycling-off error in patients with COPD (n = 8), (B) cycling-off in patients with ARDS (n = 8), (C) cycling-off error in post-operative patients, (D) trigger error in patients with COPD (n = 8), (E) trigger error in patients with ARDS, (F) trigger error in post-operative patients. Positive values indicate late cycling off, and negative values indicate early cycling off. The green line shows the median value. Comparing support levels of 100% and 150% in the same mode, aP < 0.05. ARDS: Acute respiratory distress syndrome; COPD: Chronic obstructive pulmonary disease; PSN: controlled pressure support ventilation; PSP: Conventional pressure support ventilation.
Figure 3
Figure 3
Breath density graph for relative trigger (X-axis) and cycling-off (Y-axis) errors for all breaths in all patients with COPD or ARDS and post-operative patients during PSP and PSN. The small centered box (green line) suggests “perfect” synchrony, which refers to relative timing errors of triggering and for cycling-off ≤10% of neural timings. ARDS: Acute respiratory distress syndrome; COPD: Chronic obstructive pulmonary disease; PSN: controlled pressure support ventilation; PSP: Conventional pressure support ventilation.
Figure 4
Figure 4
Inspiratory efforts for triggering and total inspiration during PSP and PSN under support levels of 100% and 150%. Median and interquartile ranges are presented. ARDS: Acute respiratory distress syndrome; COPD: Chronic obstructive pulmonary disease; PSN: controlled pressure support ventilation; PSP: Conventional pressure support ventilation; PTPes: Inspiratory Pes-time product (white bars); PTPes-trig: Pretrigger Pes-time product (gray bars).

References

    1. Spahija J, de Marchie M, Albert M, Bellemare P, Delisle S, Beck J, 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.
    1. MacIntyre NR. Clinically available new strategies for mechanical ventilatory support. Author information. Chest 1993; 104:560–565. doi: 10.1378/chest.104.2.560.
    1. Yamada Y, Du HL. Analysis of the mechanisms of expiratory asynchrony in pressure support ventilation: a mathematical approach. J Appl Physiol (1985) 2000; 88:2143–2150. doi: 10.1152/jappl.2000.88.6.2143.
    1. Tokioka H, Tanaka T, Ishizu T, Fukushima T, Iwaki T, Nakamura Y, et al. The effect of breath termination criterion on breathing patterns and the work of breathing during pressure support ventilation. Anesth Analg 2001; 92:161–165. doi: 10.1097/00000539-200101000-00031.
    1. Tassaux D, Gainnier M, Battisti A, Jolliet P. Impact of expiratory trigger setting on delayed cycling and inspiratory muscle workload. Am J Respir Crit Care Med 2005; 172:1283–1289. doi: 10.1164/rccm.200407-880OC.
    1. Thille AW, Rodriguez P, Cabello B, Lellouche F, Brochard L. Patient-ventilator asynchrony during assisted mechanical ventilation. Intensive Care Med 2006; 32:1515–1522. doi: 10.1007/s00134-006-0301-8.
    1. Terzi N, Piquilloud L, Rozé H, Mercat A, Lofaso F, Delisle S, et al. Clinical review: update on neurally adjusted ventilatory assist–report of a roundtable conference. Crit Care 2012; 16:225.doi: 10.1186/cc11297.
    1. Sinderby C, Navalesi P, Beck J, Skrobik Y, Comtois N, Friberg S, et al. Neural control of mechanical ventilation in respiratory failure. Nat Med 1999; 5:1433–1436. doi: 10.1038/71012.
    1. Kacmarek R. Proportional assist ventilation and neurally adjusted ventilatory assist. Respir Care 2011; 56:140–148. doi: 10.4187/respcare.01021.
    1. Sinderby C, Beck J. Proportional assist ventilation and neurally adjusted ventilatory assist–better approaches to patient ventilator synchrony? Clin Chest Med 2008; 29:329–342. doi: 10.1016/j.ccm.2008.01.007.
    1. Piquilloud L, Vignaux L, Bialais E, Roeseler J, Sottiaux T, Laterre P-F, et al. Neurally adjusted ventilatory assist improves patient-ventilator interaction. Intensive Care Med 2011; 37:263–271. doi: 10.1007/s00134-010-2052-9.
    1. Terzi N, Pelieu I, Guittet L, Ramakers M, Seguin A, Daubin C, et al. Neurally adjusted ventilatory assist in patients recovering spontaneous breathing after acute respiratory distress syndrome: physiological evaluation. Crit Care Med 2010; 38:1830–1837. doi: 10.1097/CCM.0b013e3181eb3c51.
    1. Colombo D, Cammarota G, Bergamaschi V, De Lucia M, Corte FD, Navalesi P. Physiologic response to varying levels of pressure support and neurally adjusted ventilatory assist in patients with acute respiratory failure. Intensive Care Med 2008; 34:2010–2018. doi: 10.1007/s00134-008-1208-3.
    1. Brander L, Leong-Poi H, Beck J, Brunet F, Hutchison SJ, Slutsky AS, 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.
    1. Patroniti N, Bellani G, Saccavino E, Zanella A, Grasselli G, Isgrò S, 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.
    1. Yonis H, Crognier L, Conil J-M, Serres I, Rouget A, Virtos M, et al. Patient ventilator synchrony in neurally adjusted ventilatory assist (NAVA) and pressure support ventilation (PSV): a prospective observational study. BMC Anesthesiol 2015; 15:117.doi: 10.1186/s12871-015-0091-z.
    1. Bellani G, Coppadoro A, Patroniti N, Turella M, Arrigoni Marocco S, Grasselli G, et al. Clinical assessment of autopositive end-expiratory pressure by diaphragmatic electrical activity during pressure support and neurally adjusted ventilatory assist. Anesthesiology 2014; 121:563–571. doi: 10.1097/ALN.0000000000000371.
    1. Cammarota G, Longhini F, Perucca R, Ronco C, Colombo D, Messina A, 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.
    1. Chiumello D, Pelosi P, Croci M, Bigatello LM, Gattinoni L. The effects of pressurization rate on breathing pattern, work of breathing, gas exchange and patient comfort in pressure support ventilation. Eur Respir J 2001; 18:107–114. doi: 10.1183/09031936.01.00083901.
    1. Liu L, Xia F, Yang Y, Longhini F, Navalesi P, Beck J, 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.
    1. Longhini F, Pan C, Xie J, Cammarota G, Bruni A, Garofalo E, et al. New setting of neurally adjusted ventilatory assist for noninvasive ventilation by facial mask: a physiologic study. Crit Care 2017; 21:170.doi: 10.1186/s13054-017-1761-7.
    1. Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, et al. ARDS Definition Task Force Acute respiratory distress syndrome: the Berlin Definition. JAMA 2012; 307:2526–2533. doi: 10.1001/jama.2012.5669.
    1. Beck J, Campoccia F, Allo JC, Brander L, Brunet F, Slutsky AS, et al. Improved synchrony and respiratory unloading by neurally adjusted ventilatory assist (NAVA) in lung-injured rabbits. Pediatr Res 2007; 61:289–294. doi: 10.1203/01.pdr.0000257324.22406.93.
    1. Lamouret O, Crognier L, Vardon Bounes F, Conil JM, Dilasser C, Raimondi T, et al. Neurally adjusted ventilatory assist (NAVA) versus pressure support ventilation: patient-ventilator interaction during invasive ventilation delivered by tracheostomy. Crit Care 2019; 23:2.doi: 10.1186/s13054-018-2288-2.
    1. Demoule A, Clavel M, Rolland-Debord C, Perbet S, Terzi N, Kouatchet A, 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.
    1. Meric H, Calabrese P, Pradon D, Lejaille M, Lofaso F, Terzi N. Physiological comparison of breathing patterns with neurally adjusted ventilatory assist (NAVA) and pressure-support ventilation to improve NAVA settings. Respir Physiol Neurobiol 2014; 195:11–18. doi: 10.1016/j.resp.2014.01.021.
    1. Beloncle F, Piquilloud L, Rittayamai N, Sinderby C, Rozé H, Brochard L. 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.
    1. Tobin MJ, Jubran A, Laghi F. Patient-ventilator interaction. Am J Respir Crit Care Med 2001; 163:1059–1063. doi: 10.1164/ajrccm.163.5.2005125.
    1. Uchiyama A, Imanaka H, Taenaka N, Nakano S, Fujino Y, Yoshiya I. A comparative evaluation of pressure-triggering and flow-triggering in pressure support ventilation (PSV) for neonates using an animal model. Anaesth Intensive Care 1995; 23:302–306. doi: 10.1177/0310057X9502300306.
    1. Barrera R, Melendez J, Ahdoot M, Huang Y, Leung D, Groeger JS. Flow triggering added to pressure support ventilation improves comfort and reduces work of breathing in mechanically ventilated patients. J Crit Care 1999; 14:172–176. doi: 10.1016/s0883-9441(99)90031-x.
    1. Xu XT, Sun Q, Xie JF, Pan C, Yang Y, Qiu HB, et al. Effect of neurally adjusted ventilatory assist on trigger of mechanical ventilation in acute exacerbation of chronic obstructive pulmonary disease patients with intrinsic positive end-expiratory pressure. Zhonghua Nei Ke Za Zhi 2019; 58:43–48. doi: 10.3760/cma.j.issn.0578-1426.2019.01.008.
    1. Whitelaw WA, Derenne JP, Milic-Emili J. Occlusion pressure as a measure of respiratory center output in conscious man. Respir Physiol 1975; 23:181–199. doi: 10.1016/0034-5687(75)90059-6.
    1. Chiumello D, Pelosi P, Taccone P, Slutsky A, Gattinoni L. Effect of different inspiratory rise time and cycling off criteria during pressure support ventilation in patients recovering from acute lung injury. Crit Care Med 2003; 31:2604–2610. doi: 10.1097/01.CCM.0000089939.11032.36.
    1. Tassaux D, Michotte JB, Gainnier M, Gratadour P, Fonseca S, Jolliet P. Expiratory trigger setting in pressure support ventilation: from mathematical model to bedside. Crit Care Med 2004; 32:1844–1850. doi: 10.1097/01.ccm.0000138561.11634.6f.
    1. Chiumello D, Polli F, Tallarini F, Chierichetti M, Motta G, Azzari S, et al. Effect of different cycling-off criteria and positive end-expiratory pressure during pressure support ventilation in patients with chronic obstructive pulmonary disease. Crit Care Med 2007; 35:2547–2552. doi: 10.1097/01.CCM.0000287594.80110.34.
    1. Doorduin J, Sinderby CA, Beck J, van der Hoeven JG, Heunks LM. Automated patient-ventilator interaction analysis during neurally adjusted non-invasive ventilation and pressure support ventilation in chronic obstructive pulmonary disease. Crit Care 2014; 18:550.doi: 10.1186/s13054-014-0550-9.
    1. Bellani G, Grassi A, Sosio S, Foti G. Plateau and driving pressure in the presence of spontaneous breathing. Intensive Care Med 2019; 45:97–98. doi: 10.1007/s00134-018-5311-9.

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