Pendelluft in hypoxemic patients resuming spontaneous breathing: proportional modes versus pressure support ventilation

Abstract

Background Internal redistribution of gas, referred to as pendelluft, is a new potential mechanism of effort-dependent lung injury. Neurally-adjusted ventilatory assist (NAVA) and proportional assist ventilation (PAV +) follow the patient’s respiratory effort and improve synchrony compared with pressure support ventilation (PSV). Whether these modes could prevent the development of pendelluft compared with PSV is unknown. We aimed to compare pendelluft magnitude during PAV + and NAVA versus PSV in patients with resolving acute respiratory distress syndrome (ARDS). Methods Patients received either NAVA, PAV + , or PSV in a crossover trial for 20-min using comparable assistance levels after controlled ventilation (> 72 h). We assessed pendelluft (the percentage of lost volume from the non-dependent lung region displaced to the dependent region during inspiration), drive (as the delta esophageal swing of the first 100 ms [ΔPes100 ms]) and inspiratory effort (as the esophageal pressure–time product per minute [PTPmin]). We performed repeated measures analysis with post-hoc tests and mixed-effects models. Results Twenty patients mechanically ventilated for 9 [5–14] days were monitored. Despite matching for a similar tidal volume, respiratory drive and inspiratory effort were slightly higher with NAVA and PAV + compared with PSV (ΔPes 100 ms of –2.8 [−3.8–−1.9] cm H2O, −3.6 [−3.9–−2.4] cm H2O and −2.1 [−2.5–−1.1] cm H2O, respectively, p < 0.001 for both comparisons; PTPmin of 155 [118–209] cm H2O s/min, 197 [145–269] cm H2O s/min, and 134 [93–169] cm H2O s/min, respectively, p < 0.001 for both comparisons). Pendelluft magnitude was higher in NAVA (12 ± 7%) and PAV + (13 ± 7%) compared with PSV (8 ± 6%), p < 0.001. Pendelluft magnitude was strongly associated with respiratory drive (β = -2.771, p-value < 0.001) and inspiratory effort (β = 0.026, p < 0.001), independent of the ventilatory mode. A higher magnitude of pendelluft in proportional modes compared with PSV existed after adjusting for PTPmin (β = 2.606, p = 0.010 for NAVA, and β = 3.360, p = 0.004 for PAV +), and only for PAV + when adjusted for respiratory drive (β = 2.643, p = 0.009 for PAV +). Conclusions Pendelluft magnitude is associated with respiratory drive and inspiratory effort. Proportional modes do not prevent its occurrence in resolving ARDS compared with PSV.

Measuring patient’s effort on the ventilator

“…3 Medical Surgical Neuro ICU, Toronto Western Hospital, University Health Network, Toronto, Canada. 4 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada. 5 Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Canada.…”

“…In addition, lung injury and systemic inflammation are primers for P-SILI and myotrauma with excessive concentric or eccentric loading [1,3]. Mechanisms of P-SILI include excessive global and regional lung stress (due to pendelluft) and increased transvascular pressure, and are directly associated with the magnitude and timing of inspiratory effort [3,4]. There is also evidence of interaction between lung and other organs such as brain and kidneys.…”