Predictors of asynchronies during assisted ventilation and its impact on clinical outcomes: The EPISYNC cohort study

Sousa, Mayson Laércio de Araújo; Magrans, Rudys; Hayashi, Fátima Kiyoko; Blanch, Lluís; Kacmarek, Robert M.; Ferreira, Juliana Carvalho

doi:10.1016/j.jcrc.2020.01.023

Cited by 27 publications

(20 citation statements)

References 23 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…AI was greater than 10% in only two patients in both PSV and NAVA, which is considered clinically important and associated with prolonged mechanical ventilation [31,32,40]. This finding may be related to the fact that most patients were still sedated during the study and that they were ventilated with low tidal volumes, which may have prevented the occurrence of ineffective triggering [41] the most common type of asynchrony [40,42]. Triggering delay was the most common type of asynchrony in our study, and it was significantly reduced in NAVA compared to PSV.…”

Section: Discussionmentioning

confidence: 95%

Neurally adjusted ventilatory assist vs. pressure support to deliver protective mechanical ventilation in patients with acute respiratory distress syndrome: a randomized crossover trial

Diniz-Silva

Moriya²,

Alencar

et al. 2020

Ann. Intensive Care

Self Cite

View full text Add to dashboard Cite

Background: Protective mechanical ventilation is recommended for patients with acute respiratory distress syndrome (ARDS), but it usually requires controlled ventilation and sedation. Using neurally adjusted ventilatory assist (NAVA) or pressure support ventilation (PSV) could have additional benefits, including the use of lower sedative doses, improved patient-ventilator interaction and shortened duration of mechanical ventilation. We designed a pilot study to assess the feasibility of keeping tidal volume (V T ) at protective levels with NAVA and PSV in patients with ARDS. Methods:We conducted a prospective randomized crossover trial in five ICUs from a university hospital in Brazil and included patients with ARDS transitioning from controlled ventilation to partial ventilatory support. NAVA and PSV were applied in random order, for 15 min each, followed by 3 h in NAVA. Flow, peak airway pressure (Paw) and electrical activity of the diaphragm (EAdi) were captured from the ventilator, and a software (Matlab, Mathworks, USA), automatically detected inspiratory efforts and calculated respiratory rate (RR) and V T . Asynchrony events detection was based on waveform analysis. Results:We randomized 20 patients, but the protocol was interrupted for five (25%) patients for whom we were unable to maintain V T below 6.5 mL/kg in PSV due to strong inspiratory efforts and for one patient for whom we could not detect EAdi signal. For the 14 patients who completed the protocol, V T was 5.8 ± 1.1 mL/kg for NAVA and 5.6 ± 1.0 mL/kg for PSV (p = 0.455) and there were no differences in RR (24 ± 7 for NAVA and 23 ± 7 for PSV, p = 0.661). Paw was greater in NAVA (21 ± 3 cmH 2 O) than in PSV (19 ± 3 cmH 2 O, p = 0.001). Most patients were under continuous sedation during the study. NAVA reduced triggering delay compared to PSV (p = 0.020) and the median asynchrony Index was 0.7% (0-2.7) in PSV and 0% (0-2.2) in NAVA (p = 0.6835).

show abstract

Section: Discussionmentioning

confidence: 95%

Neurally adjusted ventilatory assist vs. pressure support to deliver protective mechanical ventilation in patients with acute respiratory distress syndrome: a randomized crossover trial

Diniz-Silva

Moriya²,

Alencar

et al. 2020

Ann. Intensive Care

Self Cite

View full text Add to dashboard Cite

show abstract

“…Several parameters have been used to report the prevalence and the severity of asynchrony, including the proportion of asynchronous breaths in all collected breaths [ 24 ], patient-based asynchrony index with a single recording dataset [ 20 , 21 ] or merging of multiple recording datasets [ 9 ], and asynchrony index in long-term collected data [ 25 , 26 ]. The proportion of asynchronous breaths in our brain-injured patients (38% in total inspected breaths of 330,292) was higher than that reported in 27 ICU patients without brain injury (23% in 43,758 breaths) [ 24 ].…”

Section: Discussionmentioning

confidence: 99%

Patient–ventilator asynchrony in acute brain-injured patients: a prospective observational study

Luo

Zhou

et al. 2020

Ann. Intensive Care

View full text Add to dashboard Cite

Background Patient–ventilator asynchrony is common in mechanically ventilated patients and may be related to adverse outcomes. Few studies have reported the occurrence of asynchrony in brain-injured patients. We aimed to investigate the prevalence, type and severity of patient–ventilator asynchrony in mechanically ventilated patients with brain injury. Methods This prospective observational study enrolled acute brain-injured patients undergoing mechanical ventilation. Esophageal pressure monitoring was established after enrollment. Flow, airway pressure, and esophageal pressure–time waveforms were recorded for a 15-min interval, four times daily for 3 days, for visually detecting asynchrony by offline analysis. At the end of each dataset recording, the respiratory drive was determined by the airway occlusion maneuver. The asynchrony index was calculated to represent the severity. The relationship between the prevalence and the severity of asynchrony with ventilatory modes and settings, respiratory drive, and analgesia and sedation were determined. Association of severe patient–ventilator asynchrony, which was defined as an asynchrony index ≥ 10%, with clinical outcomes was analyzed. Results In 100 enrolled patients, a total of 1076 15-min waveform datasets covering 330,292 breaths were collected, in which 70,156 (38%) asynchronous breaths were detected. Asynchrony occurred in 96% of patients with the median (interquartile range) asynchrony index of 12.4% (4.3%–26.4%). The most prevalent type was ineffective triggering. No significant difference was found in either prevalence or asynchrony index among different classifications of brain injury (p > 0.05). The prevalence of asynchrony was significantly lower during pressure control/assist ventilation than during other ventilatory modes (p < 0.05). Compared to the datasets without asynchrony, the airway occlusion pressure was significantly lower in datasets with ineffective triggering (p < 0.001). The asynchrony index was significantly higher during the combined use of opioids and sedatives (p < 0.001). Significantly longer duration of ventilation and hospital length of stay after the inclusion were found in patients with severe ineffective triggering (p < 0.05). Conclusions Patient–ventilator asynchrony is common in brain-injured patients. The most prevalent type is ineffective triggering and its severity is likely related to a long duration of ventilation and hospital stay. Prevalence and severity of asynchrony are associated with ventilatory modes, respiratory drive and analgesia/sedation strategy, suggesting treatment adjustment in this particular population. Trial registration The study has been registered on 4 July 2017 in ClinicalTrials.gov (NCT03212482) (https://clinicaltrials.gov/ct2/show/NCT03212482).

show abstract

“…The accuracy reached above 95% for both types of PVA in all the ventilation modes. Asynchrony index (AI) was calculated as the number of asynchronous events divided by the number of ventilator cycles and wasted efforts (14). Details of the algorithm development is described in the Electronic Supplemental Material.…”

Section: Identification Of Dt and Ieementioning

confidence: 99%

“…Second, most techniques for the detection of PVA and other parameters requires physical presence of an expert physician at the bedside and is thus only feasible during short periods (11)(12)(13). In addition, most studies explored risk factors for PVA in a fixed-time model (14). In reality, both risk factors and PVA and compliance were time-varying (15).…”

Section: Introductionmentioning

confidence: 99%

Lung Mechanics of Mechanically Ventilated Patients With COVID-19: Analytics With High-Granularity Ventilator Waveform Data

Pan

Zhou

et al. 2020

Front. Med.

View full text Add to dashboard Cite

Background: Lung mechanics during invasive mechanical ventilation (IMV) for both prognostic and therapeutic implications; however, the full trajectory lung mechanics has never been described for novel coronavirus disease 2019 (COVID-19) patients requiring IMV. The study aimed to describe the full trajectory of lung mechanics of mechanically ventilated COVID-19 patients. The clinical and ventilator setting that can influence patient-ventilator asynchrony (PVA) and compliance were explored. Post-extubation spirometry test was performed to assess the pulmonary function after COVID-19 induced ARDS. Methods: This was a retrospective study conducted in a tertiary care hospital. All patients with IMV due to COVID-19 induced ARDS were included. High-granularity ventilator waveforms were analyzed with deep learning algorithm to obtain PVAs. Asynchrony index (AI) was calculated as the number of asynchronous events divided by the number of ventilator cycles and wasted efforts. Mortality was recorded as the vital status on hospital discharge. Results: A total of 3,923,450 respiratory cycles in 2,778 h were analyzed (average: 24 cycles/min) for seven patients. Higher plateau pressure (Coefficient: −0.90; 95% CI: −1.02 to −0.78) and neuromuscular blockades (Coefficient: −6.54; 95% CI: −9.92 to −3.16) were associated with lower AI. Survivors showed increasing compliance over time, whereas non-survivors showed persistently low compliance. Recruitment maneuver was not able to improve lung compliance. Patients were on supine position in 1,422 h (51%), followed by prone positioning (499 h, 18%), left positioning (453 h, 16%), and right positioning (404 h, 15%). As compared with supine positioning, prone positioning was associated with 2.31 ml/cmH 2 O (95% CI: 1.75 to 2.86; p < 0.001) increase in lung compliance. Spirometry tests showed that pulmonary functions were reduced to one third of the predicted values after extubation. Ge et al. Lung Mechanics in COVID-19 Conclusions: The study for the first time described full trajectory of lung mechanics of patients with COVID-19. The result showed that prone positioning was associated with improved compliance; higher plateau pressure and use of neuromuscular blockades were associated with lower risk of AI.

show abstract

Predictors of asynchronies during assisted ventilation and its impact on clinical outcomes: The EPISYNC cohort study

Cited by 27 publications

References 23 publications

Neurally adjusted ventilatory assist vs. pressure support to deliver protective mechanical ventilation in patients with acute respiratory distress syndrome: a randomized crossover trial

Neurally adjusted ventilatory assist vs. pressure support to deliver protective mechanical ventilation in patients with acute respiratory distress syndrome: a randomized crossover trial

Patient–ventilator asynchrony in acute brain-injured patients: a prospective observational study

Lung Mechanics of Mechanically Ventilated Patients With COVID-19: Analytics With High-Granularity Ventilator Waveform Data

Contact Info

Product

Resources

About