Defining patient-ventilator asynchrony severity according to recurrence.
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ABSTRACT:
SUBMITTER: See KC
PROVIDER: S-EPMC7223983 | biostudies-literature | 2020 Apr
REPOSITORIES: biostudies-literature
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Defining patient-ventilator asynchrony severity according to recurrence.
See Kay Choong KC Sahagun Juliet J Taculod Juvel J
Intensive care medicine 20200224 4
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Project description:BackgroundPatient-ventilator asynchrony is common in mechanically ventilated patients and may be related to adverse outcomes. Few studies have reported the occurrence of asynchrony in brain-injured patients. We aimed to investigate the prevalence, type and severity of patient-ventilator asynchrony in mechanically ventilated patients with brain injury.MethodsThis prospective observational study enrolled acute brain-injured patients undergoing mechanical ventilation. Esophageal pressure monitoring was established after enrollment. Flow, airway pressure, and esophageal pressure-time waveforms were recorded for a 15-min interval, four times daily for 3 days, for visually detecting asynchrony by offline analysis. At the end of each dataset recording, the respiratory drive was determined by the airway occlusion maneuver. The asynchrony index was calculated to represent the severity. The relationship between the prevalence and the severity of asynchrony with ventilatory modes and settings, respiratory drive, and analgesia and sedation were determined. Association of severe patient-ventilator asynchrony, which was defined as an asynchrony index ≥ 10%, with clinical outcomes was analyzed.ResultsIn 100 enrolled patients, a total of 1076 15-min waveform datasets covering 330,292 breaths were collected, in which 70,156 (38%) asynchronous breaths were detected. Asynchrony occurred in 96% of patients with the median (interquartile range) asynchrony index of 12.4% (4.3%-26.4%). The most prevalent type was ineffective triggering. No significant difference was found in either prevalence or asynchrony index among different classifications of brain injury (p > 0.05). The prevalence of asynchrony was significantly lower during pressure control/assist ventilation than during other ventilatory modes (p < 0.05). Compared to the datasets without asynchrony, the airway occlusion pressure was significantly lower in datasets with ineffective triggering (p < 0.001). The asynchrony index was significantly higher during the combined use of opioids and sedatives (p < 0.001). Significantly longer duration of ventilation and hospital length of stay after the inclusion were found in patients with severe ineffective triggering (p < 0.05).ConclusionsPatient-ventilator asynchrony is common in brain-injured patients. The most prevalent type is ineffective triggering and its severity is likely related to a long duration of ventilation and hospital stay. Prevalence and severity of asynchrony are associated with ventilatory modes, respiratory drive and analgesia/sedation strategy, suggesting treatment adjustment in this particular population. Trial registration The study has been registered on 4 July 2017 in ClinicalTrials.gov (NCT03212482) ( https://clinicaltrials.gov/ct2/show/NCT03212482 ).
| S-EPMC7570406 | biostudies-literature
Project description:BackgroundRespiratory therapists (RTs) play a crucial role in managing mechanically ventilated patients, such as addressing patient-ventilator asynchronies that may contribute to patient harm. Waveform analysis is integral to the evaluation of patient-ventilator asynchronies; despite this, no published studies have assessed the ability of practicing RTs to interpret ventilator waveform abnormalities.MethodsThe study took place between June 2017-February 2019. Eighty-six RTs from 2 academic medical centers enrolled in a one-day mechanical ventilation course. The scores of 79 first-time attendees were included in the analysis. Prior to and following the course, RTs were asked to identify abnormalities on a 5-question, multiple-choice ventilator waveform exam. They were also asked to provide a self-assessment of their ventilator management skills on a 1 (complete novice) to 5 (expert) scale.ResultsInitial scores were low but improved after one day of ventilator instruction (19.4 ± 17.1 vs 29.6 ± 19.0, P < .001). No significant difference was noted in mean confidence levels between the pre- and post-course assessments (3.8 ± 0.9 vs 3.8 ± 1.0, P = .56). RTs with fewer years of clinical experience (0-10 y) had a statistically significant improvement in their post-course test scores relative to their pre-course scores (0-5 y: 12.5 ± 10.1 to 46.0 ± 10.8, P < .001; 6-10 y: 18.7 ± 15.8 to 32.1 ± 16.7, P = .02), whereas those with > 11 y of clinical experience did not (11-20 y: 22.4 ± 15.5 to 27.4 ± 19.0, P = .44; 21+ y: 19.6 ± 22.1 to 15.3 ± 13.8, P = .50).ConclusionsRTs may benefit from additional training in ventilator waveform interpretation, especially early in their clinical training. More work is needed to determine the optimal length and content of a mechanical ventilation curriculum for RTs.
| S-EPMC9994037 | biostudies-literature
Project description:Patient-ventilator asynchrony (PVA) is commonly encountered during mechanical ventilation of critically ill patients. Estimates of PVA incidence vary widely. Type, risk factors, and consequences of PVA remain unclear. We aimed to measure the incidence and identify types of PVA, characterize risk factors for development, and explore the relationship between PVA and outcome among critically ill, mechanically ventilated adult patients admitted to medical, surgical, and medical-surgical intensive care units in a large academic institution staffed with varying provider training background. A single center, retrospective cohort study of all adult critically ill patients undergoing invasive mechanical ventilation for ≥ 12 h. A total of 676 patients who underwent 696 episodes of mechanical ventilation were included. Overall PVA occurred in 170 (24%) episodes. Double triggering 92(13%) was most common, followed by flow starvation 73(10%). A history of smoking, and pneumonia, sepsis, or ARDS were risk factors for overall PVA and double triggering (all P < 0.05). Compared with volume targeted ventilation, pressure targeted ventilation decreased the occurrence of events (all P < 0.01). During volume controlled synchronized intermittent mandatory ventilation and pressure targeted ventilation, ventilator settings were associated with the incidence of overall PVA. The number of overall PVA, as well as double triggering and flow starvation specifically, were associated with worse outcomes and fewer hospital-free days (all P < 0.01). Double triggering and flow starvation are the most common PVA among critically ill, mechanically ventilated patients. Overall incidence as well as double triggering and flow starvation PVA specifically, portend worse outcome.
| S-EPMC8196026 | biostudies-literature
Project description:BackgroundStable severe chronic obstructive pulmonary disease (COPD) patients with chronic hypercapnic respiratory failure treated by nocturnal bi-level positive pressure non-invasive ventilation (NIV) may experience severe morning deventilation dyspnea. We hypothesised that in these patients, progressive hyperinflation, resulting from inappropriate ventilator settings, leads to patient-ventilator asynchrony (PVA) with a high rate of unrewarded inspiratory efforts and morning discomfort.MethodsPolysomnography (PSG), diaphragm electromyogram and transcutaneous capnography (PtcCO(2)) under NIV during two consecutive nights using baseline ventilator settings on the first night, then, during the second night, adjustment of ventilator parameters under PSG with assessment of impact of settings changes on sleep, patient-ventilator synchronisation, morning arterial blood gases and morning dyspnea.ResultsEight patients (61 ± 8 years, FEV(1) 30 ± 8% predicted, residual volume 210 ± 30% predicted) were included. In all patients, pressure support was decreased during setting adjustments, as well as tidal volume, while respiratory rate increased without any deleterious effect on nocturnal PtcCO(2) or morning PaCO(2). PVA index, initially high (40 ± 30%) during the baseline night, decreased significantly after adjusting ventilator settings (p = 0.0009), as well as subjective perception of PVA leaks, and morning dyspnea while quality of sleep improved.ConclusionThe subgroup of COPD patients treated by home NIV, who present marked deventilation dyspnea and unrewarded efforts may benefit from adjustment of ventilator settings under PSG or polygraphy.
| S-EPMC3497941 | biostudies-literature
Project description:BackgroundImproved patient-ventilator asynchrony (PVA) identification using waveform analysis by critical care physicians (CCPs) may improve patient outcomes. This study aimed to assess the ability of CCPs to identify different types of PVAs using waveform analysis as well as factors related to this ability.MethodsWe surveyed 12 university-affiliated medical ICUs (MICUs) in Tunisia. CCPs practicing in these MICUs were asked to visually identify 4 clinical cases, each corresponding to a different PVA. We collected the following characteristics regarding CCPs: scientific grade, years of experience, prior training in mechanical ventilation, prior exposure to waveform analysis, and the characteristics of the MICUs in which they practice. Respondents were categorized into 2 groups based on their ability to correctly identify PVAs (defined as the correct identification of at least 3 of the 4 PVA cases). Univariate analysis was performed to identify factors related to the correct identification of PVA.ResultsAmong 136 included CCPs, 72 (52.9%) responded to the present survey. The respondents comprised 59 (81.9%) residents, and 13 (18.1%) senior physicians. Further, 50 (69.4%) respondents had attended prior training in mechanical ventilation. Moreover, 21 (29.2%) of the respondents could correctly identify PVAs. Double-triggering was the most frequently identified PVA type, 43 (59.7%), followed by auto-triggering, 36 (50%); premature cycling, 28 (38.9%); and ineffective efforts, 25 (34.7%). Univariate analysis indicated that senior physicians had a better ability to correctly identify PVAs than residents (7 [53.8%] vs 14 [23.7%], P = .044).ConclusionsThe present study revealed a significant deficiency in the accurate visual identification of PVAs among CCPs in the MICUs. When compared to residents, senior physicians exhibited a notably superior aptitude for correctly recognizing PVAs.
| S-EPMC10898468 | biostudies-literature
Project description:BackgroundPatient-ventilator asynchrony (PVA) is a common problem in patients undergoing invasive mechanical ventilation (MV) in the intensive care unit (ICU), and may accelerate lung injury and diaphragm mis-contraction. The impact of PVA on clinical outcomes has not been systematically evaluated. Effective interventions (except for closed-loop ventilation) for reducing PVA are not well established.MethodsWe performed a systematic review and meta-analysis to investigate the impact of PVA on clinical outcomes in patients undergoing MV (Part A) and the effectiveness of interventions for patients undergoing MV except for closed-loop ventilation (Part B). We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, ClinicalTrials.gov, and WHO-ICTRP until August 2020. In Part A, we defined asynchrony index (AI) ≥ 10 or ineffective triggering index (ITI) ≥ 10 as high PVA. We compared patients having high PVA with those having low PVA.ResultsEight studies in Part A and eight trials in Part B fulfilled the eligibility criteria. In Part A, five studies were related to the AI and three studies were related to the ITI. High PVA may be associated with longer duration of mechanical ventilation (mean difference, 5.16 days; 95% confidence interval [CI], 2.38 to 7.94; n = 8; certainty of evidence [CoE], low), higher ICU mortality (odds ratio [OR], 2.73; 95% CI 1.76 to 4.24; n = 6; CoE, low), and higher hospital mortality (OR, 1.94; 95% CI 1.14 to 3.30; n = 5; CoE, low). In Part B, interventions involving MV mode, tidal volume, and pressure-support level were associated with reduced PVA. Sedation protocol, sedation depth, and sedation with dexmedetomidine rather than propofol were also associated with reduced PVA.ConclusionsPVA may be associated with longer MV duration, higher ICU mortality, and higher hospital mortality. Physicians may consider monitoring PVA and adjusting ventilator settings and sedatives to reduce PVA. Further studies with adjustment for confounding factors are warranted to determine the impact of PVA on clinical outcomes. Trial registration protocols.io (URL: https://www.protocols.io/view/the-impact-of-patient-ventilator-asynchrony-in-adu-bsqtndwn , 08/27/2020).
| S-EPMC8365272 | biostudies-literature
Project description:Introduction and aimStudies 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.MethodsA 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.ResultsAll 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.ConclusionsThere 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.
| S-EPMC7196928 | biostudies-literature
Project description:Background: Patient-ventilator asynchrony is common during pressure support ventilation (PSV) because of the constant cycling-off criteria and variation of respiratory system mechanical properties in individual patients. Automatic adjustment of inspiratory triggers and cycling-off criteria based on waveforms might be a useful tool to improve patient-ventilator asynchrony during PSV. Method: Twenty-four patients were enrolled and were ventilated using PSV with different cycling-off criteria of 10% (PS10), 30% (PS30), 50% (PS50), and automatic adjustment PSV (PSAUTO). Patient-ventilator interactions were measured. Results: The total asynchrony index (AI) and NeuroSync index were consistently lower in PSAUTO when compared with PS10, PS30, and PS50, (P < 0.05). The benefit of PSAUTO in reducing the total AI was mainly because of the reduction of the micro-AI but not the macro-AI. PSAUTO significantly improved the relative cycling-off error when compared with prefixed controlled PSV (P < 0.05). PSAUTO significantly reduced the trigger error and inspiratory effort for the trigger when compared with a prefixed trigger. However, total inspiratory effort, breathing patterns, and respiratory drive were not different among modes. Conclusions: When compared with fixed cycling-off criteria, an automatic adjustment system improved patient-ventilator asynchrony without changes in breathing patterns during PSV. The automatic adjustment system could be a useful tool to titrate more personalized mechanical ventilation.
| S-EPMC8632800 | biostudies-literature
Project description:Background and objectives: Patient-ventilator asynchronies (PVAs) are common in mechanically ventilated patients. However, the epidemiology of PVAs and its impact on clinical outcome remains controversial. The current study aims to evaluate the epidemiology and risk factors of PVAs and their impact on clinical outcomes using big data analytics. Methods: The study was conducted in a tertiary care hospital; all patients with mechanical ventilation from June to December 2019 were included for analysis. Negative binomial regression and distributed lag non-linear models (DLNM) were used to explore risk factors for PVAs. PVAs were included as a time-varying covariate into Cox regression models to investigate its influence on the hazard of mortality and ventilator-associated events (VAEs). Results: A total of 146 patients involving 50,124 h and 51,451,138 respiratory cycles were analyzed. The overall mortality rate was 15.6%. Double triggering was less likely to occur during day hours (RR: 0.88; 95% CI: 0.85-0.90; p < 0.001) and occurred most frequently in pressure control ventilation (PCV) mode (median: 3; IQR: 1-9 per hour). Ineffective effort was more likely to occur during day time (RR: 1.09; 95% CI: 1.05-1.13; p < 0.001), and occurred most frequently in PSV mode (median: 8; IQR: 2-29 per hour). The effect of sedatives and analgesics showed temporal patterns in DLNM. PVAs were not associated mortality and VAE in Cox regression models with time-varying covariates. Conclusions: Our study showed that counts of PVAs were significantly influenced by time of the day, ventilation mode, ventilation settings (e.g., tidal volume and plateau pressure), and sedatives and analgesics. However, PVAs were not associated with the hazard of VAE or mortality after adjusting for protective ventilation strategies such as tidal volume, plateau pressure, and positive end expiratory pressure (PEEP).
| S-EPMC7724969 | biostudies-literature
Project description:IntroductionPatient-ventilator asynchrony is common during the entire period of invasive mechanical ventilation (MV) and is associated with worse clinical outcomes. However, risk factors associated with asynchrony are not completely understood. The main objectives of this study are to estimate the incidence of asynchrony during invasive MV and its association with respiratory mechanics and other baseline patient characteristics.Methods and analysisWe designed a prospective cohort study of patients admitted to the intensive care unit (ICU) of a university hospital. Inclusion criteria are adult patients under invasive MV initiated for less than 72 hours, and with expectation of remaining under MV for more than 24 hours. Exclusion criteria are high flow bronchopleural fistula, inability to measure respiratory mechanics and previous tracheostomy. Baseline assessment includes clinical characteristics of patients at ICU admission, including severity of illness, reason for initiation of MV, and measurement of static mechanics of the respiratory system. We will capture ventilator waveforms during the entire MV period that will be analysed with dedicated software (Better Care, Barcelona, Spain), which automatically identifies several types of asynchrony and calculates the asynchrony index (AI). We will use a linear regression model to identify risk factors associated with AI. To assess the relationship between survival and AI we will use Kaplan-Meier curves, log rank tests and Cox regression. The calculated sample size is 103 patients. The statistical analysis will be performed by the software R Programming (www.R-project.org) and will be considered statistically significant if the p value is less than 0.05.Ethics and disseminationThe study was approved by the Ethics Committee of Instituto do Coração, School of Medicine, University of São Paulo, Brazil, and informed consent was waived due to the observational nature of the study. We aim to disseminate the study findings through peer-reviewed publications and national and international conference presentations.Trial registration numberNCT02687802; Pre-results.
| S-EPMC6537972 | biostudies-literature