Reverse triggering in a patient with ARDS

Yonis, Hodane; Gobert, Florent; Tapponnier, Romain; Guérin, Claude

doi:10.1007/s00134-015-3702-8

Cited by 15 publications

(8 citation statements)

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“…Patient-ventilator asynchrony causes a series of adverse clinical effects and is associated with unwanted outcomes, such as discomfort, dyspnea, worsening of pulmonary gas exchange, increased respiratory effort, diaphragmatic injury, decreased quantity and quality of sleep, increased use of sedation, increased use of neuromuscular blockade, an increased duration of MV, and increased mortality. (20)(21)(22)(23) Symptoms of "air hunger" or "excessive inspiratory effort", that is, dyspnea, although rarely studied, are very common during MV.…”

Section: Generalmentioning

confidence: 99%

Patient-ventilator asynchrony

et al. 2018

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Patient-v entilator asynchrony (PVA) is a mismatch between the patient, regarding time, flow, volume, or pressure demands of the patient respiratory system, and the ventilator, which supplies such demands, during mechanical ventilation (MV). It is a common phenomenon, with incidence rates ranging from 10% to 85%. PVA might be due to factors related to the patient, to the ventilator, or both. The most common PVA types are those related to triggering, such as ineffective effort, auto-triggering, and double triggering; those related to premature or delayed cycling; and those related to insufficient or excessive flow. Each of these types can be detected by visual inspection of volume, flow, and pressure waveforms on the mechanical ventilator display. Specific ventilatory strategies can be used in combination with clinical management, such as controlling patient pain, anxiety, fever, etc. Deep sedation should be avoided whenever possible. PVA has been associated with unwanted outcomes, such as discomfort, dyspnea, worsening of pulmonary gas exchange, increased work of breathing, diaphragmatic injury, sleep impairment, and increased use of sedation or neuromuscular blockade, as well as increases in the duration of MV, weaning time, and mortality. Proportional assist ventilation and neurally adjusted ventilatory assist are modalities of partial ventilatory support that reduce PVA and have shown promise. This article reviews the literature on the types and causes of PVA, as well as the methods used in its evaluation, its potential implications in the recovery process of critically ill patients, and strategies for its resolution.

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Section: Generalmentioning

confidence: 99%

Patient-ventilator asynchrony

et al. 2018

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“…On the other hand, RT was always observed in the deeply sedated ARDS patients who didn’t receive neuromuscular blocking agent in most studies ( Akoumianaki et al, 2013 ; Bourenne et al, 2019 ; Kassis et al, 2020 ), which were similar to ours. By contrast, RT occurred in awake ventilated ARDS patients had been reported in two case reports ( Yonis et al, 2015 ; Taiga et al, 2018 ). In our study we captured a very interesting waveform from No.2 patient, he appeared a transition from assist mechanical breath to intermittent (unstable) RT and stable RT, followed by an increment of ΔPeso and PL, when the sedative drug was reduced, even though the RASS score did not change.…”

Section: Discussionmentioning

confidence: 93%

“…Since the research published by Akoumianaki ( Akoumianaki et al, 2013 ), the term “reverse trigger (RT)” has attracted the attention of the intensivist in the worldwide ( Yonis et al, 2015 ; Taiga et al, 2018 ; Takeshi et al, 2018 ; Bourenne et al, 2019 ). Reverse trigger is a type of patient-ventilator dyssynchrony whereby a diaphragm muscle contraction occurs after a mandatory breath initiated by the ventilator ( Akoumianaki et al, 2013 ).…”

Section: Introductionmentioning

confidence: 99%

Reverse Trigger in Ventilated Non-ARDS Patients: A Phenomenon Can Not Be Ignored!

et al. 2021

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IntroductionThe role of reverse trigger (RT) was unknown in ventilated non-acute respiratory distress syndrome (ARDS) patients. So we conducted a retrospective study to evaluate the incidence, characteristics and physiologic consequence of RT in such population.MethodSix ventilated non-ARDS patients were included, the esophageal balloon catheter were placed for measurements of respiratory mechanics in all patients. And the data were analyzed to identified the occurrence of RT, duration of the entrainment, the entrainment pattern or ratio, the phase difference (dP) and the phase angle (θ), phenotypes, Effects and clinical correlations of RT.ResultRT was detected in four patients of our series (66.7%), and the occurrence of RT varying from 19 to 88.6% of their recording time in these 4 patients. One patient (No.2) showed a stable 1:1 ratio and Mid-cycle RT was the most common phenotype. However, the remained patients showed a mixed ratios, and Late RT was the most common phenotype, followed by RT with breath stacking. The average values of mean phase delay and phase angles were 0.39s (0.32, 0.98) and 60.52° (49.66, 102.24). Mean phase delay and phase angles were shorter in early reverse triggering with early and delayed relaxation, and longer in mid, late RT and RT with breath stacking. Pmus was variable between patients and phenotypes, and larger Pmus was generated in Early RT, Delayed Relaxation and mid cycle RT. When the RT occurred, the Peso increased 17.27 (4.91, 19.71) cmH2O compared to the controlled breathing, and the average value of incremental ΔPeso varied widely inter and intra patients (Table 3B and Figure 1). Larger ΔPeso was always generated in Early RT, Delayed Relaxation and mid cycle RT, accompanied by an significant increase of PL with 19.12 (0.75) cmH2O and 16.10 (6.23) cmH2O.ConclusionRT could also be observed in ventilated non-ARDS patients. The characteristics of pattern and phenotype was similar to RT in ARDS patients to a large extent. And RT appeared to alter lung stress and delivered volumes.

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“…PVA may result in adverse consequences including increased respiratory workload, patient discomfort, deterioration in gas exchange, diaphragmatic injury, and/or patient self-in icted lung injury. PVA is associated with worse clinical outcomes objectively identi ed by increased duration of mechanical ventilation, length of intensive care unit (ICU) and hospital stay, and mortality (12)(13)(14)(15)(16)(17)(18). To date studies of PVA have mainly examined speci c patient populations and/or ventilator modes and been limited by the timing and length of observations.…”

Section: Introductionmentioning

confidence: 99%

Patient-Ventilator Asynchrony in Critically-Ill Adult Patients Undergoing Invasive Mechanical Ventilation: Incidence, Risk Factors and Outcomes

Zhou

Holets

et al. 2020

Preprint

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Background: Patient-ventilator asynchrony (PVA) is commonly encountered during mechanical ventilation of critically ill patients. Estimates of PVA incidence vary widely. Type, risk factors, and consequences of PVA remain unclear. We aimed to measure the incidence and identify types of PVA, characterize risk factors for development, and explore the relationship between PVA and outcome among critically ill, mechanically ventilated adult patients admitted to medical, surgical, and medical-surgical intensive care units in a large academic institution staffed with varying provider training background.Methods: A single center, retrospective cohort study of all adult critically ill patients undergoing invasive mechanical ventilation for ≥12 hours.Results: A total of 676 patients who underwent 696 episodes of mechanical ventilation were included. Overall PVA occurred in 170 (24%) episodes. Double triggering 92(13%) was most common, followed by flow starvation 73(10%). A history of smoking, and pneumonia, sepsis, or ARDS were risk factors for overall PVA and double triggering (all P<0.05). Compared with volume targeted ventilation, pressure targeted ventilation decreased the occurrence of events (all P<0.01). During volume controlled synchronized intermittent mandatory ventilation and pressure targeted ventilation, ventilator settings were associated with the incidence of overall PVA. The number of overall PVA, as well as double triggering and flow starvation specifically, were associated with worse outcomes and fewer hospital-free days (all P<0.01).Conclusion: Double triggering and flow starvation are the most common PVA among critically ill, mechanically ventilated patients. Overall incidence as well as double triggering and flow starvation PVA specifically, portend worse outcome.

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Reverse triggering in a patient with ARDS

Cited by 15 publications

References 0 publications

Patient-ventilator asynchrony

Patient-ventilator asynchrony

Reverse Trigger in Ventilated Non-ARDS Patients: A Phenomenon Can Not Be Ignored!

Patient-Ventilator Asynchrony in Critically-Ill Adult Patients Undergoing Invasive Mechanical Ventilation: Incidence, Risk Factors and Outcomes

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