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Souza Leite W, Novaes A, Bandeira M, Olympia Ribeiro E, dos Santos AM, de Moura PH, Morais CC, Rattes C, Richtrmoc MK, Souza J, Correia de Lima GH, Pinheiro Modolo NS, Gonçalves ACE, Ramirez Gonzalez CA, do Amparo Andrade M, Dornelas De Andrade A, Cunha Brandão D, Lima Campos S. Patient-ventilator asynchrony in conventional ventilation modes during short-term mechanical ventilation after cardiac surgery: randomized clinical trial. Multidiscip Respir Med 2020; 15:650. [PMID: 32373344 PMCID: PMC7196928 DOI: 10.4081/mrm.2020.650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 03/27/2020] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION AND AIM Studies regarding asynchrony in patients in the cardiac postoperative period are still only a few. The main objective of our study was to compare asynchronies incidence and its index (AI) in 3 different modes of ventilation (volume-controlled ventilation [VCV], pressure-controlled ventilation [PCV] and pressure-support ventilation [PSV]) after ICU admission for postoperative care. METHODS A prospective parallel randomised trialin the setting of a non-profitable hospital in Brazil. The participants were patients scheduled for cardiac surgery. Patients were randomly allocated to VCV or PCV modes of ventilation and later both groups were transitioned to PSV mode. RESULTS All data were recorded for 5 minutes in each of the three different phases: T1) in assisted breath, T2) initial spontaneous breath and T3) final spontaneous breath, a marking point prior to extubation. Asynchronies were detected and counted by visual inspection method by two independent investigators. Reliability, inter-rater agreement of asynchronies, asynchronies incidence, total and specific asynchrony indexes (AIt and AIspecific) and odds of AI ≥10% weighted by total asynchrony were analysed. A total of 17 patients randomly allocated to the VCV (n=9) or PCV (n=8) group completed the study. High inter-rated agreement for AIt (ICC 0.978; IC95%, 0,963-0.987) and good reliability (r=0.945; p<0.001) were found. Eighty-two % of patients presented asynchronies, although only 7% of their total breathing cycles were asynchronous. Early cycling and double triggering had the highest rates of asynchrony with no difference between groups. The highest odds of AI ≥10% were observed in VCV regardless the phase: OR 2.79 (1.36-5.73) in T1 vs T2, p=0.005; OR 2.61 (1.27-5.37) in T1 vs T3, p=0.009 and OR 4.99 (2.37-10.37) in T2 vs T3, p<0.001. CONCLUSIONS There was a high incidence of breathing asynchrony in postoperative cardiac patients, especially when initially ventilated in VCV. VCV group had a higher chance of AI ≥10% and this chance remained high in the following PSV phases.
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Affiliation(s)
- Wagner Souza Leite
- Department of Physical Therapy, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | - Alita Novaes
- Department of Physical Therapy, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | - Monique Bandeira
- Department of Physical Therapy, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | | | | | - Pedro Henrique de Moura
- Department of Physical Therapy, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | - Caio César Morais
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Catarina Rattes
- Department of Physical Therapy, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | | | - Juliana Souza
- Department of Physical Therapy, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | | | - Norma Sueli Pinheiro Modolo
- Department of Anaesthesiology, Institute of Bioscience, School of Medicine, UNESP-Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
| | | | | | - Maria do Amparo Andrade
- Department of Physical Therapy, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | | | - Daniella Cunha Brandão
- Department of Physical Therapy, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | - Shirley Lima Campos
- Department of Physical Therapy, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
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Carvalho NC, Portes LL, Beda A, Tallarico LMS, Aguirre LA. Recurrence plots for the assessment of patient-ventilator interactions quality during invasive mechanical ventilation. CHAOS (WOODBURY, N.Y.) 2018; 28:085707. [PMID: 30180626 DOI: 10.1063/1.5020371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 05/10/2018] [Indexed: 06/08/2023]
Abstract
Inappropriate patient-ventilator interactions' (PVI) quality is associated with adverse clinical consequences, such as patient anxiety/fear and increased need of sedative and paralytic agents. Thus, technological devices/tools to support the recognition and monitoring of different PVI quality are of great interest. In the present study, we investigate two tools based on a recent landmark study which applied recurrence plots (RPs) and recurrence quantification analysis (RQA) techniques in non-invasive mechanical ventilation. Our interest is in how this approach could be a daily part of critical care professionals' routine (which are not familiar with dynamical systems theory methods and concepts). Two representative time series of three typical PVI "scenarios" were selected from 6 critically ill patients subjected to invasive mechanical ventilation. First, both the (i) main signatures in RPs and the (ii) respective signals that provide the most (visually) discriminant RPs were identified. This allows one to propose a visual identification protocol for PVIs' quality through the RPs' overall aspect. Support for the effectiveness of this visual based assessment tool is given by a RQA-based assessment tool. A statistical analysis shows that both the recurrence rate and the Shannon entropy are able to identify the selected PVI scenarios. It is then expected that the development of an objective method can reliably identify PVI quality, where the results corroborate the potential of RPs/RQA in the field of respiratory pattern analysis.
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Affiliation(s)
- Nadja C Carvalho
- Graduate Program in Electrical Engineering (PPGEE), Universidade Federal de Minas Gerais, Av. Antônio Carlos 6627, 31270-901 Belo Horizonte, Minas Gerais, Brazil
| | - Leonardo L Portes
- Graduate Program in Electrical Engineering (PPGEE), Universidade Federal de Minas Gerais, Av. Antônio Carlos 6627, 31270-901 Belo Horizonte, Minas Gerais, Brazil
| | - Alessandro Beda
- Departamento de Engenharia Eletrônica, Universidade Federal de Minas Gerais, Av. Antônio Carlos 6627, 31270-901 Belo Horizonte, Minas Gerais, Brazil
| | - Lucinara M S Tallarico
- Hospital Risoleta Tolentino Neves, Rua das Gabirobas 1, 31744-012 Belo Horizonte, Minas Gerais, Brazil
| | - Luis A Aguirre
- Departamento de Engenharia Eletrônica, Universidade Federal de Minas Gerais, Av. Antônio Carlos 6627, 31270-901 Belo Horizonte, Minas Gerais, Brazil
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Holanda MA, Vasconcelos RDS, Ferreira JC, Pinheiro BV. Patient-ventilator asynchrony. ACTA ACUST UNITED AC 2018; 44:321-333. [PMID: 30020347 DOI: 10.1590/s1806-37562017000000185] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 09/03/2017] [Indexed: 11/22/2022]
Abstract
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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Affiliation(s)
- Marcelo Alcantara Holanda
- . Departamento de Medicina Clínica, Universidade Federal do Ceará, Fortaleza (CE) Brasil.,. Programa de Pós-Graduação de Mestrado em Ciências Médicas, Universidade Federal do Ceará, Fortaleza (CE) Brasil
| | | | - Juliana Carvalho Ferreira
- . Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Bruno Valle Pinheiro
- . Faculdade de Medicina, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo (SP) Brasil
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Chiew YS, Tan CP, Chase JG, Chiew YW, Desaive T, Ralib AM, Mat Nor MB. Assessing mechanical ventilation asynchrony through iterative airway pressure reconstruction. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2018; 157:217-224. [PMID: 29477430 DOI: 10.1016/j.cmpb.2018.02.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 01/05/2018] [Accepted: 02/02/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND AND OBJECTIVE Respiratory mechanics estimation can be used to guide mechanical ventilation (MV) but is severely compromised when asynchronous breathing occurs. In addition, asynchrony during MV is often not monitored and little is known about the impact or magnitude of asynchronous breathing towards recovery. Thus, it is important to monitor and quantify asynchronous breathing over every breath in an automated fashion, enabling the ability to overcome the limitations of model-based respiratory mechanics estimation during asynchronous breathing ventilation. METHODS An iterative airway pressure reconstruction (IPR) method is used to reconstruct asynchronous airway pressure waveforms to better match passive breathing airway waveforms using a single compartment model. The reconstructed pressure enables estimation of respiratory mechanics of airway pressure waveform essentially free from asynchrony. Reconstruction enables real-time breath-to-breath monitoring and quantification of the magnitude of the asynchrony (MAsyn). RESULTS AND DISCUSSION Over 100,000 breathing cycles from MV patients with known asynchronous breathing were analyzed. The IPR was able to reconstruct different types of asynchronous breathing. The resulting respiratory mechanics estimated using pressure reconstruction were more consistent with smaller interquartile range (IQR) compared to respiratory mechanics estimated using asynchronous pressure. Comparing reconstructed pressure with asynchronous pressure waveforms quantifies the magnitude of asynchronous breathing, which has a median value MAsyn for the entire dataset of 3.8%. CONCLUSION The iterative pressure reconstruction method is capable of identifying asynchronous breaths and improving respiratory mechanics estimation consistency compared to conventional model-based methods. It provides an opportunity to automate real-time quantification of asynchronous breathing frequency and magnitude that was previously limited to invasively method only.
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Affiliation(s)
| | - Chee Pin Tan
- School of Engineering, Monash University, Subang Jaya, Malaysia.
| | - J Geoffrey Chase
- Centre for Bioengineering, University of Canterbury, Christchurch, New Zealand.
| | | | - Thomas Desaive
- GIGA Cardiovascular Science, University of Liege, Liege, Belgium.
| | - Azrina Md Ralib
- Department of Intensive Care, International Islamic University Malaysia Medical Centre, Kuantan, Malaysia.
| | - Mohd Basri Mat Nor
- Department of Intensive Care, International Islamic University Malaysia Medical Centre, Kuantan, Malaysia.
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Abstract
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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Affiliation(s)
- Marcelo Alcantara Holanda
- . Departamento de Medicina Clínica, Universidade Federal do Ceará, Fortaleza (CE) Brasil.,. Programa de Pós-Graduação de Mestrado em Ciências Médicas, Universidade Federal do Ceará, Fortaleza (CE) Brasil
| | | | - Juliana Carvalho Ferreira
- . Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Bruno Valle Pinheiro
- . Faculdade de Medicina, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo (SP) Brasil
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