1
|
Frequency and Risk Factors for Reverse Triggering in Pediatric Acute Respiratory Distress Syndrome during Synchronized Intermittent Mandatory Ventilation. Ann Am Thorac Soc 2021; 18:820-829. [PMID: 33326335 DOI: 10.1513/annalsats.202008-1072oc] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: Reverse triggering (RT) occurs when respiratory effort begins after a mandatory breath is initiated by the ventilator. RT may exacerbate ventilator-induced lung injury and lead to breath stacking.Objectives: We sought to describe the frequency and risk factors for RT among patients with acute respiratory distress syndrome (ARDS) and identify risk factors for breath stacking.Methods: We performed a secondary analysis of physiologic data from children on synchronized intermittent mandatory pressure-controlled ventilation enrolled in a single-center randomized controlled trial for ARDS. When children had a spontaneous effort on esophageal manometry, waveforms were recorded and independently analyzed by two investigators to identify RT.Results: We included 81,990 breaths from 100 patient-days and 36 patients. Overall, 2.46% of breaths were RTs, occurring in 15/36 patients (41.6%). A higher tidal volume and a minimal difference between neural respiratory rate and set ventilator rate were independently associated with RT (P = 0.001) in multivariable modeling. Breath stacking occurred in 534 (26.5%) of 2,017 RT breaths and in 14 (93.3%) of 15 patients with RT. In multivariable modeling, breath stacking was more likely to occur when total airway Δpressure (peak inspiratory pressure - positive end-expiratory pressure [PEEP]) at the time patient effort began, peak inspiratory pressure, PEEP, and Δpressure were lower and when patient effort started well after the ventilator-initiated breath (higher phase angle) (all P < 0.05). Together, these parameters were highly predictive of breath stacking (area under the curve, 0.979).Conclusions: Patients with higher tidal volume who have a set ventilator rate close to their spontaneous respiratory rate are more likely to have RT, which results in breath stacking >25% of the time.Clinical trial registered with ClinicalTrials.gov (NCT03266016).
Collapse
|
2
|
Pham T, Montanya J, Telias I, Piraino T, Magrans R, Coudroy R, Damiani LF, Mellado Artigas R, Madorno M, Blanch L, Brochard L. Automated detection and quantification of reverse triggering effort under mechanical ventilation. Crit Care 2021; 25:60. [PMID: 33588912 PMCID: PMC7883535 DOI: 10.1186/s13054-020-03387-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/12/2020] [Indexed: 12/31/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Tài Pham
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada. .,Interdepartmental Division of Critical Care Medicine, University of Toronto, 209 Victoria St, Toronto, ON, M5B 1T8, Canada. .,Université Paris-Saclay, AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, FHU SEPSIS, Groupe de recherche clinique CARMAS, Le Kremlin-Bicêtre, France.
| | | | - Irene Telias
- grid.415502.7Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 30 Bond St, Toronto, ON M5B 1W8 Canada ,grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, 209 Victoria St, Toronto, ON M5B 1T8 Canada ,grid.231844.80000 0004 0474 0428Division of Respirology, Department of Medicine, University Health Network, Toronto, Canada ,grid.492573.e0000 0004 6477 6457Sinai Health System, Toronto, Canada
| | - Thomas Piraino
- grid.415502.7St. Michael’s Hospital, Unity Health Toronto, Toronto, Canada ,grid.25073.330000 0004 1936 8227Division of Critical Care, Department of Anesthesia, McMaster University, Hamilton, Canada
| | | | - Rémi Coudroy
- grid.415502.7Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 30 Bond St, Toronto, ON M5B 1W8 Canada ,grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, 209 Victoria St, Toronto, ON M5B 1T8 Canada ,grid.411162.10000 0000 9336 4276Médecine Intensive Réanimation, CHU de Poitiers, Poitiers, France ,grid.11166.310000 0001 2160 6368INSERM CIC 1402, Groupe ALIVE, Université de Poitiers, Poitiers, France
| | - L. Felipe Damiani
- grid.415502.7Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 30 Bond St, Toronto, ON M5B 1W8 Canada ,grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, 209 Victoria St, Toronto, ON M5B 1T8 Canada ,grid.7870.80000 0001 2157 0406Departamento Ciencias de la Salud, Carrera de Kinesiología, Faculdad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Ricard Mellado Artigas
- grid.415502.7Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 30 Bond St, Toronto, ON M5B 1W8 Canada ,grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, 209 Victoria St, Toronto, ON M5B 1T8 Canada ,grid.410458.c0000 0000 9635 9413Surgical ICU, Department of Anesthesia, Hospital Clínic, Barcelona, Spain
| | - Matías Madorno
- grid.441574.70000000090137393Instituto Tecnológico de Buenos Aires (ITBA), Buenos Aires, Argentina
| | - Lluis Blanch
- grid.7080.f0000 0001 2296 0625Critical Care Center, Hospital Universitari Parc Taulí, Institut D’Investigació I Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain ,grid.413448.e0000 0000 9314 1427Biomedical Research Networking Center in Respiratory Disease (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Laurent Brochard
- grid.415502.7Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 30 Bond St, Toronto, ON M5B 1W8 Canada ,grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, 209 Victoria St, Toronto, ON M5B 1T8 Canada
| | | |
Collapse
|