Reverse Triggering Causes an Injurious Inflation Pattern during Mechanical Ventilation

Yoshida, Toyohiko; Nakamura, Maria Aparecida Miyuki; Morais, Caio C. A.; Amato, Marcelo B. P.; Kavanagh, Brian P.

doi:10.1164/rccm.201804-0649le

Cited by 49 publications

(34 citation statements)

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“…Of major interest, reverse triggering (RT) is a specific form of dyssynchrony defined by the presence of a respiratory muscle contraction following a passive mechanical insufflation as if the contraction was "triggered by" the ventilator [6]. It has been described in intubated patients receiving sedation under controlled ventilation and seems to be very frequent [7][8][9][10][11][12][13][14][15]. This phenomenon might constitute a regular entrainment (phase locking) of the respiratory rhythm to periodic insufflation, as described in animals [16,17] and healthy humans [18], but it may also be more irregular and can even occur in brain-dead patients [10].…”

Section: Introductionmentioning

confidence: 99%

“…When the effort generated is strong enough, it induces breath stacking, often misinterpreted to be caused by double triggering (in which the same patient's inspiratory effort would trigger the first and second mechanical insufflation). Reverse triggering could impact patients' outcomes through several mechanisms, such as increased tidal volume during inspiration, breath stacking, or through pendelluft during the inspiratory phase [14]. On the one hand, it can generate diaphragm injury when generating strong eccentric contractions during exhalation [19], but on the other hand, when small, diaphragmatic contractions related to RT could be beneficial by preventing muscle disuse and atrophy in sedated patients.…”

Section: Introductionmentioning

confidence: 99%

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Automated detection and quantification of reverse triggering effort under mechanical ventilation

Pham

Montanyà²,

Telias

et al. 2021

Crit Care

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Background Reverse triggering (RT) is a dyssynchrony defined by a respiratory muscle contraction following a passive mechanical insufflation. It is potentially harmful for the lung and the diaphragm, but its detection is challenging. Magnitude of effort generated by RT is currently unknown. Our objective was to validate supervised methods for automatic detection of RT using only airway pressure (Paw) and flow. A secondary objective was to describe the magnitude of the efforts generated during RT. Methods We developed algorithms for detection of RT using Paw and flow waveforms. Experts having Paw, flow and esophageal pressure (Pes) assessed automatic detection accuracy by comparison against visual assessment. Muscular pressure (Pmus) was measured from Pes during RT, triggered breaths and ineffective efforts. Results Tracings from 20 hypoxemic patients were used (mean age 65 ± 12 years, 65% male, ICU survival 75%). RT was present in 24% of the breaths ranging from 0 (patients paralyzed or in pressure support ventilation) to 93.3%. Automatic detection accuracy was 95.5%: sensitivity 83.1%, specificity 99.4%, positive predictive value 97.6%, negative predictive value 95.0% and kappa index of 0.87. Pmus of RT ranged from 1.3 to 36.8 cmH20, with a median of 8.7 cmH20. RT with breath stacking had the highest levels of Pmus, and RTs with no breath stacking were of similar magnitude than pressure support breaths. Conclusion An automated detection tool using airway pressure and flow can diagnose reverse triggering with excellent accuracy. RT generates a median Pmus of 9 cmH2O with important variability between and within patients. Trial registration BEARDS, NCT03447288.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Automated detection and quantification of reverse triggering effort under mechanical ventilation

Pham

Montanyà²,

Telias

et al. 2021

Crit Care

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“…Su et al 74 reported that 30% of subjects with ARDS exhibit reverse-triggering that developed in the late inspiratory phase (41%) and early expiratory phase (59%), and that reverse-triggering was associated with breath-stacking with a larger proportion of V T and maximum transpulmonary pressure fluctuations compared to passive breaths, suggesting that the mechanism of injury is not only volutrauma but also barotrauma. Interestingly, in one subject with ARDS, Yoshida et al 75 observed that reverse-triggering without breath-stacking elicited an injurious inflation pattern with asymmetric stretch of the dependent lung at constant V T .…”

Section: Reverse-triggering: Entrainment Phenomenonmentioning

confidence: 99%

“…70,76 Observational studies have often reported reverse-triggering in heavily sedated subjects with ARDS, but less information is available about the prevalence of reverse-triggering in other clinical scenarios. 70,74,75 Although de Haro et al 44 reported that double-triggering induced by invasive ventilation occurred in 34.6% of a cohort of 67 general ICU subjects, further studies are needed to investigate this issue in different groups of patients to better understand reverse-triggering and its clinical implications. time, and integrated-volume waveforms from ventilator screens; tracings from balloon-tipped esophageal catheters; electrical activity of the diaphragm, which is available on some ventilators; and more recently, automated algorithms (10).…”

Section: Reverse-triggering: Entrainment Phenomenonmentioning

confidence: 99%

Monitoring Asynchrony During Invasive Mechanical Ventilation

et al. 2020

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Mechanical ventilation in critically ill patients must effectively unload inspiratory muscles and provide safe ventilation (ie, enhancing gas exchange, protect the lungs and the diaphragm). To do that, the ventilator should be in synchrony with patient's respiratory rhythm. The complexity of such interplay leads to several concerning issues that clinicians should be able to recognize. Asynchrony between the patient and the ventilator may induce several deleterious effects that require a proper physiological understanding to recognize and manage them. Different tools have been developed and proposed beyond the careful analysis of the ventilator waveforms to help clinicians in the decision-making process. Moreover, appropriate handling of asynchrony requires clinical skills, physiological knowledge, and suitable medication management. New technologies and devices are changing our daily practice, from automated real-time recognition of asynchronies and their distribution during mechanical ventilation, to smart alarms and artificial intelligence algorithms based on physiological big data and personalized medicine. Our goal as clinicians is to provide care of patients based on the most accurate and current knowledge, and to incorporate new technological methods to facilitate and improve the care of the critically ill.

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“…Yoshida et al [18] recently demonstrated how reverse triggering can worsen pre-existing lung injury through a pendelluft effect from non-dependent lung areas toward dependent areas due to poor transmission of the diaphragm contraction across the pleural surface in an injured lung. Moreover, reverse triggering can result in increased strain and stretch due to breath stacking during double cycling caused by insufficient assistance [19, 23].…”

Section: Main Textmentioning

confidence: 99%

Patient-ventilator asynchronies during mechanical ventilation: current knowledge and research priorities

Haro

Ochagavía

López-Aguilar

et al. 2019

ICMx

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Background Mechanical ventilation is common in critically ill patients. This life-saving treatment can cause complications and is also associated with long-term sequelae. Patient-ventilator asynchronies are frequent but underdiagnosed, and they have been associated with worse outcomes. Main body Asynchronies occur when ventilator assistance does not match the patient’s demand. Ventilatory overassistance or underassistance translates to different types of asynchronies with different effects on patients. Underassistance can result in an excessive load on respiratory muscles, air hunger, or lung injury due to excessive tidal volumes. Overassistance can result in lower patient inspiratory drive and can lead to reverse triggering, which can also worsen lung injury. Identifying the type of asynchrony and its causes is crucial for effective treatment. Mechanical ventilation and asynchronies can affect hemodynamics. An increase in intrathoracic pressure during ventilation modifies ventricular preload and afterload of ventricles, thereby affecting cardiac output and hemodynamic status. Ineffective efforts can decrease intrathoracic pressure, but double cycling can increase it. Thus, asynchronies can lower the predictive accuracy of some hemodynamic parameters of fluid responsiveness. New research is also exploring the psychological effects of asynchronies. Anxiety and depression are common in survivors of critical illness long after discharge. Patients on mechanical ventilation feel anxiety, fear, agony, and insecurity, which can worsen in the presence of asynchronies. Asynchronies have been associated with worse overall prognosis, but the direct causal relation between poor patient-ventilator interaction and worse outcomes has yet to be clearly demonstrated. Critical care patients generate huge volumes of data that are vastly underexploited. New monitoring systems can analyze waveforms together with other inputs, helping us to detect, analyze, and even predict asynchronies. Big data approaches promise to help us understand asynchronies better and improve their diagnosis and management. Conclusions Although our understanding of asynchronies has increased in recent years, many questions remain to be answered. Evolving concepts in asynchronies, lung crosstalk with other organs, and the difficulties of data management make more efforts necessary in this field.

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Reverse Triggering Causes an Injurious Inflation Pattern during Mechanical Ventilation

Cited by 49 publications

References 10 publications

Automated detection and quantification of reverse triggering effort under mechanical ventilation

Automated detection and quantification of reverse triggering effort under mechanical ventilation

Monitoring Asynchrony During Invasive Mechanical Ventilation

Patient-ventilator asynchronies during mechanical ventilation: current knowledge and research priorities

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