Electrical Activity of the Diaphragm During Reverse Triggering - A Case Report

Abstract

Reverse triggering is defined as diaphragmatic muscle contraction triggered by mandatory breath of ventilator. Reverse triggering induced double cycling and large tidal volume (V T ) in Pressure Control Ventilation (PCV).An 81-year-old male was admitted to the ICU after tricuspid valve plasty. A close observation of graphic monitor showed a deflection of pressure waveform in the middle of mandatory breath. Electric activity of the diaphragm (EAdi) revealed diaphragmatic contraction following mandatory breath. When diaphragmatic contraction started at the end of mandatory breath it induced double-cycling. When it started at the middle of mandatory breath V T increased. As spontaneous breathing increased, reverse triggering disappeared. While the consequences of reverse triggering are under discussion, in our case it led double cycling and large V T , and it might be injurious. We should recognize it is more common than expected.

Reverse Triggering: An Introduction to Diagnosis, Management, and Pharmacologic Implications

“…Counter-intuitive to traditional clinical reasoning, reverse triggering incidence may increase with depth of sedation and has been reported during assist control ventilation under deep sedation in multiple studies ( Akoumianaki et al, 2013 ; Chanques et al, 2013 ; He et al, 2018 ). One case of reverse triggering in a patient with ARDS reported resolution of asynchrony when sedation was discontinued and the patient regained consciousness ( Ueno et al, 2017 ). However, recent literature has been unable to show a significant correlation between sedative dosing and incidence of reverse triggering ( Rodriguez et al, 2020a ).…”