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      Double Cycling During Mechanical Ventilation : Frequency, Mechanisms, and Physiologic Implications*

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          Abstract

          Double cycling generates larger than expected tidal volumes that contribute to lung injury. We analyzed the incidence, mechanisms, and physiologic implications of double cycling during volume- and pressure-targeted mechanical ventilation in critically ill patients.

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          Patient-ventilator asynchrony during assisted mechanical ventilation.

          Arnaud W Thille, Pablo Rodriguez, Belen Cabello … (2006)
          The incidence, pathophysiology, and consequences of patient-ventilator asynchrony are poorly known. We assessed the incidence of patient-ventilator asynchrony during assisted mechanical ventilation and we identified associated factors. Sixty-two consecutive patients requiring mechanical ventilation for more than 24 h were included prospectively as soon as they triggered all ventilator breaths: assist-control ventilation (ACV) in 11 and pressure-support ventilation (PSV) in 51. Gross asynchrony detected visually on 30-min recordings of flow and airway pressure was quantified using an asynchrony index. Fifteen patients (24%) had an asynchrony index greater than 10% of respiratory efforts. Ineffective triggering and double-triggering were the two main asynchrony patterns. Asynchrony existed during both ACV and PSV, with a median number of episodes per patient of 72 (range 13-215) vs. 16 (4-47) in 30 min, respectively (p=0.04). Double-triggering was more common during ACV than during PSV, but no difference was found for ineffective triggering. Ineffective triggering was associated with a less sensitive inspiratory trigger, higher level of pressure support (15 cmH(2)O, IQR 12-16, vs. 17.5, IQR 16-20), higher tidal volume, and higher pH. A high incidence of asynchrony was also associated with a longer duration of mechanical ventilation (7.5 days, IQR 3-20, vs. 25.5, IQR 9.5-42.5). One-fourth of patients exhibit a high incidence of asynchrony during assisted ventilation. Such a high incidence is associated with a prolonged duration of mechanical ventilation. Patients with frequent ineffective triggering may receive excessive levels of ventilatory support.
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            The application of esophageal pressure measurement in patients with respiratory failure.

            Evangelia Akoumianaki, Salvatore Maggiore, Franco Valenza … (2014)
            This report summarizes current physiological and technical knowledge on esophageal pressure (Pes) measurements in patients receiving mechanical ventilation. The respiratory changes in Pes are representative of changes in pleural pressure. The difference between airway pressure (Paw) and Pes is a valid estimate of transpulmonary pressure. Pes helps determine what fraction of Paw is applied to overcome lung and chest wall elastance. Pes is usually measured via a catheter with an air-filled thin-walled latex balloon inserted nasally or orally. To validate Pes measurement, a dynamic occlusion test measures the ratio of change in Pes to change in Paw during inspiratory efforts against a closed airway. A ratio close to unity indicates that the system provides a valid measurement. Provided transpulmonary pressure is the lung-distending pressure, and that chest wall elastance may vary among individuals, a physiologically based ventilator strategy should take the transpulmonary pressure into account. For monitoring purposes, clinicians rely mostly on Paw and flow waveforms. However, these measurements may mask profound patient-ventilator asynchrony and do not allow respiratory muscle effort assessment. Pes also permits the measurement of transmural vascular pressures during both passive and active breathing. Pes measurements have enhanced our understanding of the pathophysiology of acute lung injury, patient-ventilator interaction, and weaning failure. The use of Pes for positive end-expiratory pressure titration may help improve oxygenation and compliance. Pes measurements make it feasible to individualize the level of muscle effort during mechanical ventilation and weaning. The time is now right to apply the knowledge obtained with Pes to improve the management of critically ill and ventilator-dependent patients.
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              Esophageal and transpulmonary pressure in the clinical setting: meaning, usefulness and perspectives.

              Tommaso Mauri, Takeshi Yoshida, Giacomo Bellani … (2016)
              Esophageal pressure (Pes) is a minimally invasive advanced respiratory monitoring method with the potential to guide management of ventilation support and enhance specific diagnoses in acute respiratory failure patients. To date, the use of Pes in the clinical setting is limited, and it is often seen as a research tool only.
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                Author and article information

                Journal
                Title: Critical Care Medicine
                Abbreviated Title: Critical Care Medicine
                Publisher: Ovid Technologies (Wolters Kluwer Health)
                ISSN (Print): 0090-3493
                Publication date Created: 2018
                Publication date (Print): September 2018
                Volume: 46
                Issue: 9
                Pages: 1385-1392
                Article
                DOI: 10.1097/CCM.0000000000003256
                PubMed ID: 29985211
                SO-VID: 2f48e5a7-30cd-4d88-a12c-1431a21dbd87
                Copyright © © 2018
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