Advanced modes of mechanical ventilation and optimal targeting schemes

Staay, M. van der; Chatburn, Robert L

doi:10.1186/s40635-018-0195-0

Cited by 24 publications

(27 citation statements)

References 39 publications

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“…During assisted ventilation, mechanical power is provided by the mechanical ventilator in tandem with the respiratory muscles [30]. New theoretical [31] and experimental [32] studies have dissociated the mechanical power imparted by the machine and that imparted by the respiratory muscles during assisted mechanical ventilation. However, further studies are needed to definitively determine mechanical power during assisted ventilation.…”

Section: As Long As Mechanical Power Is Low Can I Modify Ventilator mentioning

confidence: 99%

Power to mechanical power to minimize ventilator-induced lung injury?

Silva

Ball

Rocco

et al. 2019

ICMx

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Mechanical ventilation is a life-supportive therapy, but can also promote damage to pulmonary structures, such as epithelial and endothelial cells and the extracellular matrix, in a process referred to as ventilator-induced lung injury (VILI). Recently, the degree of VILI has been related to the amount of energy transferred from the mechanical ventilator to the respiratory system within a given timeframe, the so-called mechanical power. During controlled mechanical ventilation, mechanical power is composed of parameters set by the clinician at the bedside—such as tidal volume ( V T ), airway pressure (Paw), inspiratory airflow ( V ′), respiratory rate (RR), and positive end-expiratory pressure (PEEP) level—plus several patient-dependent variables, such as peak, plateau, and driving pressures. Different mathematical equations are available to calculate mechanical power, from pressure-volume (PV) curves to more complex formulas which consider both dynamic (kinetic) and static (potential) components; simpler methods mainly consider the dynamic component. Experimental studies have reported that, even at low levels of mechanical power, increasing V T causes lung damage. Mechanical power should be normalized to the amount of ventilated pulmonary surface; the ratio of mechanical power to the alveolar area exposed to energy delivery is called “intensity.” Recognizing that mechanical power may reflect a conjunction of parameters which may predispose to VILI is an important step toward optimizing mechanical ventilation in critically ill patients. However, further studies are needed to clarify how mechanical power should be taken into account when choosing ventilator settings.

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Section: As Long As Mechanical Power Is Low Can I Modify Ventilator mentioning

confidence: 99%

Power to mechanical power to minimize ventilator-induced lung injury?

Silva

Ball

Rocco

et al. 2019

ICMx

View full text Add to dashboard Cite

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“…This approach was demonstrated feasible in clinical practice in most patients. It should be noted, however, that measurements of effort as provided by the ventilator may underestimate the patient's true work of breathing, particularly when intrinsic PEEP is high [79]. Target values may be difficult to achieve in patients with excessive respiratory drive and impaired respiratory mechanics as lung-protective reflexes may be overridden [35,57].…”

Section: Inspiratory Effort Targetsmentioning

confidence: 99%

“…Automated ventilation modes such as adaptive support ventilation (ASV) and SmartCare™ continuously adapt certain ventilator settings to keep the patient’s respiratory variables within target ranges set by the clinician [ 4 , 80 ]. Although NAVA, PAV+, and automated modes all integrate closed-loop principles, it is important to stress that automated modes do not deliver proportional assist, nor directly measure patient effort.…”

Section: Differences With Automated Modesmentioning

confidence: 99%

“…Although NAVA, PAV+, and automated modes all integrate closed-loop principles, it is important to stress that automated modes do not deliver proportional assist, nor directly measure patient effort. In contrast, automated modes incorporate algorithms that attempt to target a desired outcome by automatically modifying ventilator settings according to changes in the patient’s condition [ 80 ]. This may reduce the clinician’s workload.…”

Section: Differences With Automated Modesmentioning

confidence: 99%

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Proportional modes of ventilation: technology to assist physiology

et al. 2020

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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 PaCO 2 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.

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“…In a recent methodological publication on advanced modes of mechanical ventilation and optimal targeting schemes [9], van der Staay and Chatburn pointed out that Otis’ equation was originally derived to better understand the energetics of unassisted spontaneous breathing, assuming inspiratory muscle pressure to follow a sinusoidal waveform during inspiration. However, all abovementioned adaptive ventilation modes are based on pressure-controlled mechanical ventilation, which delivers a “square-wave” inspiratory pressure during mandatory breaths.…”

Section: Introductionmentioning

confidence: 99%

Adaptive mechanical ventilation with automated minimization of mechanical power—a pilot randomized cross-over study

Becher¹,

Adelmeier²,

Frerichs³

et al. 2019

Crit Care

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BackgroundAdaptive mechanical ventilation automatically adjusts respiratory rate (RR) and tidal volume (VT) to deliver the clinically desired minute ventilation, selecting RR and VT based on Otis’ equation on least work of breathing. However, the resulting VT may be relatively high, especially in patients with more compliant lungs. Therefore, a new mode of adaptive ventilation (adaptive ventilation mode 2, AVM2) was developed which automatically minimizes inspiratory power with the aim of ensuring lung-protective combinations of VT and RR. The aim of this study was to investigate whether AVM2 reduces VT, mechanical power, and driving pressure (ΔPstat) and provides similar gas exchange when compared to adaptive mechanical ventilation based on Otis’ equation.MethodsA prospective randomized cross-over study was performed in 20 critically ill patients on controlled mechanical ventilation, including 10 patients with acute respiratory distress syndrome (ARDS). Each patient underwent 1 h of mechanical ventilation with AVM2 and 1 h of adaptive mechanical ventilation according to Otis’ equation (adaptive ventilation mode, AVM). At the end of each phase, we collected data on VT, mechanical power, ΔP, PaO2/FiO2 ratio, PaCO2, pH, and hemodynamics.ResultsComparing adaptive mechanical ventilation with AVM2 to the approach based on Otis’ equation (AVM), we found a significant reduction in VT both in the whole study population (7.2 ± 0.9 vs. 8.2 ± 0.6 ml/kg, p < 0.0001) and in the subgroup of patients with ARDS (6.6 ± 0.8 ml/kg with AVM2 vs. 7.9 ± 0.5 ml/kg with AVM, p < 0.0001). Similar reductions were observed for ΔPstat (whole study population: 11.5 ± 1.6 cmH2O with AVM2 vs. 12.6 ± 2.5 cmH2O with AVM, p < 0.0001; patients with ARDS: 11.8 ± 1.7 cmH2O with AVM2 and 13.3 ± 2.7 cmH2O with AVM, p = 0.0044) and total mechanical power (16.8 ± 3.9 J/min with AVM2 vs. 18.6 ± 4.6 J/min with AVM, p = 0.0024; ARDS: 15.6 ± 3.2 J/min with AVM2 vs. 17.5 ± 4.1 J/min with AVM, p = 0.0023). There was a small decrease in PaO2/FiO2 (270 ± 98 vs. 291 ± 102 mmHg with AVM, p = 0.03; ARDS: 194 ± 55 vs. 218 ± 61 with AVM, p = 0.008) and no differences in PaCO2, pH, and hemodynamics.ConclusionsAdaptive mechanical ventilation with automated minimization of inspiratory power may lead to more lung-protective ventilator settings when compared with adaptive mechanical ventilation according to Otis’ equation.Trial registrationThe study was registered at the German Clinical Trials Register (DRKS00013540) on December 1, 2017, before including the first patient.

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Advanced modes of mechanical ventilation and optimal targeting schemes

Cited by 24 publications

References 39 publications

Power to mechanical power to minimize ventilator-induced lung injury?

Power to mechanical power to minimize ventilator-induced lung injury?

Proportional modes of ventilation: technology to assist physiology

Adaptive mechanical ventilation with automated minimization of mechanical power—a pilot randomized cross-over study

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