Reverse Triggering during Controlled Ventilation: From Physiology to Clinical Management

Rodrigues, Antenor; Telias, Irene; Damiani, L Felipe; Brochard, Laurent

doi:10.1164/rccm.202208-1477ci

Cited by 12 publications

(11 citation statements)

References 55 publications

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“…Reverse triggering (RT) is a form of asynchrony described by Akoumanaki et al in 2013, occurring in up to 30–55% of sedated patients on controlled or assist-control ventilation [ 5 ]. RT is defined as a patient inspiratory effort occurring after the onset of mechanical insufflation, appearing to be triggered by the ventilator’s insufflation [ 6 ].…”

Section: Introductionmentioning

confidence: 99%

“…RT is defined as a patient inspiratory effort occurring after the onset of mechanical insufflation, appearing to be triggered by the ventilator’s insufflation [ 6 ]. While the mechanisms leading to RT are not fully understood, a frequent mechanism is that of respiratory entrainment; the establishment of a fixed, repetitive rhythm between a patients respiratory pattern generator and an external stimulus (here mechanical insufflation) [ 5 ]. The physiological consequences of RT are not yet known.…”

Section: Introductionmentioning

confidence: 99%

“…Therefore, RT can be present without (most frequently) or with breath-stacking. The circumstances facilitating RT are not fully understood but have been associated with sedation [ 10 ] and low tidal volume ventilation [ 5 , 11 , 12 ]. In experimental models RT could be easily induced using reduced tidal volume [ 7 ].…”

Section: Introductionmentioning

confidence: 99%

“…RT is diagnosed when the patient’s respiratory effort is initiated after the start of mechanical insufflation. Frequently, this may occur in a regular, recurring pattern, suggesting that the patient’s respiratory cycle is ‘entrained’ to the set rate of the ventilator, but this may not always be the case and the pattern can appear irregular [ 5 ]. In the absence of such monitoring, RT can still be detected in the flow and pressure ventilator waveform characteristic of RT [ 13 ].…”

Section: Introductionmentioning

confidence: 99%

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Reverse triggering ? a novel or previously missed phenomenon?

Jackson,

Kim,

Moroz

et al. 2024

Ann. Intensive Care

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Background Reverse triggering (RT) was described in 2013 as a form of patient-ventilator asynchrony, where patient’s respiratory effort follows mechanical insufflation. Diagnosis requires esophageal pressure (Pes) or diaphragmatic electrical activity (EAdi), but RT can also be diagnosed using standard ventilator waveforms. Hypothesis We wondered (1) how frequently RT would be present but undetected in the figures from literature, especially before 2013; (2) whether it would be more prevalent in the era of small tidal volumes after 2000. Methods We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials, from 1950 to 2017, with key words related to asynchrony to identify papers with figures including ventilator waveforms expected to display RT if present. Experts labelled waveforms. ‘Definite’ RT was identified when Pes or EAdi were in the tracing, and ‘possible’ RT when only flow and pressure waveforms were present. Expert assessment was compared to the author’s descriptions of waveforms. Results We found 65 appropriate papers published from 1977 to now, containing 181 ventilator waveforms. 21 cases of ‘possible’ RT and 25 cases of ‘definite’ RT were identified by the experts. 18.8% of waveforms prior to 2013 had evidence of RT. Most cases were published after 2000 (1 before vs. 45 after, p = 0.03). 54% of RT cases were attributed to different phenomena. A few cases of identified RT were already described prior to 2013 using different terminology (earliest in 1997). While RT cases attributed to different phenomena decreased after 2013, 60% of ‘possible’ RT remained missed. Conclusion RT has been present in the literature as early as 1997, but most cases were found after the introduction of low tidal volume ventilation in 2000. Following 2013, the number of undetected cases decreased, but RT are still commonly missed. Prior Abstract Reverse Triggering, A Missed Phenomenon in the Literature. Critical Care Canada Forum 2019 Abstracts. Can J Anesth/J Can Anesth 67 (Suppl 1), 1–162 (2020). https://doi-org.myaccess.library.utoronto.ca/https://doi.org/10.1007/s12630-019-01552-z.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Reverse triggering ? a novel or previously missed phenomenon?

Jackson,

Kim,

Moroz

et al. 2024

Ann. Intensive Care

Self Cite

View full text Add to dashboard Cite

show abstract

“…Reverse triggering dyssynchrony occurs when passive mechanical insufflation by the ventilator triggers a reflex inspiratory effort on the part of the patient, an effort that often continues even after the ventilator has cycled into the expiratory phase and may or may not also result in breath stacking dyssynchrony. The mechanism underlying the latter form of dyssynchrony is uncertain, although it is generally observed in patients who are deeply sedated or recovering some minimal level of neural respiratory drive and rhythm as sedation is lifted (3).…”

mentioning

confidence: 99%