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Jackson R, Kim A, Moroz N, Damiani LF, Grieco DL, Piraino T, Friedrich JO, Mercat A, Telias I, Brochard LJ. Reverse triggering ? a novel or previously missed phenomenon? Ann Intensive Care 2024; 14:78. [PMID: 38776032 PMCID: PMC11111438 DOI: 10.1186/s13613-024-01303-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 04/27/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Reverse triggering (RT) was described in 2013 as a form of patient-ventilator asynchrony, where patient's respiratory effort follows mechanical insufflation. Diagnosis requires esophageal pressure (Pes) or diaphragmatic electrical activity (EAdi), but RT can also be diagnosed using standard ventilator waveforms. HYPOTHESIS We wondered (1) how frequently RT would be present but undetected in the figures from literature, especially before 2013; (2) whether it would be more prevalent in the era of small tidal volumes after 2000. METHODS We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials, from 1950 to 2017, with key words related to asynchrony to identify papers with figures including ventilator waveforms expected to display RT if present. Experts labelled waveforms. 'Definite' RT was identified when Pes or EAdi were in the tracing, and 'possible' RT when only flow and pressure waveforms were present. Expert assessment was compared to the author's descriptions of waveforms. RESULTS We found 65 appropriate papers published from 1977 to now, containing 181 ventilator waveforms. 21 cases of 'possible' RT and 25 cases of 'definite' RT were identified by the experts. 18.8% of waveforms prior to 2013 had evidence of RT. Most cases were published after 2000 (1 before vs. 45 after, p = 0.03). 54% of RT cases were attributed to different phenomena. A few cases of identified RT were already described prior to 2013 using different terminology (earliest in 1997). While RT cases attributed to different phenomena decreased after 2013, 60% of 'possible' RT remained missed. CONCLUSION RT has been present in the literature as early as 1997, but most cases were found after the introduction of low tidal volume ventilation in 2000. Following 2013, the number of undetected cases decreased, but RT are still commonly missed. Reverse Triggering, A Missed Phenomenon in the Literature. Critical Care Canada Forum 2019 Abstracts. Can J Anesth/J Can Anesth 67 (Suppl 1), 1-162 (2020). https://doi-org.myaccess.library.utoronto.ca/ https://doi.org/10.1007/s12630-019-01552-z .
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Affiliation(s)
- Robert Jackson
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute and St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Audery Kim
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute and St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Nikolay Moroz
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute and St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Department of Respiratory Therapy, McGill University Health Centre, Montreal, QC, Canada
| | - L Felipe Damiani
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute and St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Departamento Ciencias de la Salud, Carrera de Kinesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Domenico Luca Grieco
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute and St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Anesthesia, Italy
- Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Thomas Piraino
- Department of Anesthesia, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Jan O Friedrich
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute and St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Alain Mercat
- Medical ICU and Vent'Lab, University Hospital of Angers, University of Angers, 4 Rue Larrey, Angers Cedex 9, 49933, France
| | - Irene Telias
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute and St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Laurent J Brochard
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute and St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
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