Patient Ventilator Dyssynchrony: Types, Frequency and Patterns in Critically Ill Adults

Patient ventilator dyssynchrony (PVD) occurs frequently, but little is known about the types, frequency and patterns of PVD for longer than 30 minutes. Deeper levels of sedation are associated with PVD. Evaluation of ventilator graphics and the ability to identify PVD should assist clinicians to optimize patient ventilator interactions and promote earlier interventions. The purpose of this study was to identify the different types, frequency and patterns of PVD in critically ill adults and determine the effect of sedation level on PVD. Thirty medical and surgical ICU adult patients were enrolled; 27 were used for analysis. Pressure/time and flow/ time waveform data were collected using the Noninvasive Cardiac Output monitor for up to 90 minutes per subject. Blinded waveform analysis was performed. Sedation level was measured every 20 minutes. A Dyssynchrony Index (DI) and PVD Type Indices were used to describe PVD frequency. Lag analysis was used to detect associated patterns of PVD. PVD occurred during all phases of ventilated breaths and during each of the ventilatory modes used. Heretofore undocumented dyssynchrony in the form of patient gasp PVD, active triggers and combined PVDs were found. The most common type of PVD was Ineffective Trigger (63%), followed by Premature Termination-Flow (17%), Premature Termination (9%), Multiple Trigger (1%), Flow (0.87%) and Delayed Termination (0.09%). The overall frequency of dyssynchronous breaths in the sample was 23% of total breaths analyzed, however 93% of subjects experienced at least one incident of PVD. The overall median DI (Interquartile Range [IQR]) was 4% (1% - 9%) with Ineffective Trigger Index having the highest median index (1.78%). The high DI group (6 subjects, 22%) had a DI (IQR) of 61% (42% - 85%). Seventy seven percent of subjects experienced multiple types of PVD. Premature Termination was followed by Multiple Triggers starting at 3 seconds, but Delayed Termination was followed by Ineffective Triggers, starting at 30 seconds. Clinicians need to recognize PVD, since this is a critical step in evaluating patient ventilator interaction and providing subsequent intervention. PVD interpretation is complex requiring clinicians to clearly understand the operational function of ventilator modes and waveform alterations that occur

An Exploration of Critical Care Professionals\u27 Strategies to Enhance Daily Implementation of the Assess, Prevent, and Manage Pain; Both Spontaneous Awakening and Breathing Trials; Choice of Analgesia and Sedation; Delirium Assess, Prevent, and Manage; Early Mobility and Exercise; and Family Engagement and Empowerment: A Group Concept Mapping Study

OBJECTIVES: The goals of this exploratory study were to engage professionals from the Society for Critical Care Medicine ICU Liberation Collaborative ICUs to: 1) conceptualize strategies to enhance daily implementation of the Assess, prevent, and manage pain; Both spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assess, prevent, and manage; Early mobility and exercise; and Family engagement and empowerment (ABCDEF) bundle from different perspectives and 2) identify strategies to prioritize for implementation. DESIGN: Mixed-methods group concept mapping over 8 months using an online method. Participants provided strategies in response to a prompt about what was needed for successful daily ABCDEF bundle implementation. Responses were summarized into a set of unique statements and then rated on a 5-point scale on degree of necessity (essential) and degree to which currently used. SETTING: Sixty-eight academic, community, and federal ICUs. PARTICIPANTS: A total of 121 ICU professionals consisting of frontline and leadership professionals. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A final set of 76 strategies (reduced from 188 responses) were suggested: education (16 strategies), collaboration (15 strategies), processes and protocols (13 strategies), feedback (10 strategies), sedation/pain practices (nine strategies), education (eight strategies), and family (five strategies). Nine strategies were rated as very essential but infrequently used: adequate staffing, adequate mobility equipment, attention to (patient\u27s) sleep, open discussion and collaborative problem solving, nonsedation methods to address ventilator dyssynchrony, specific expectations for night and day shifts, education of whole team on interdependent nature of the bundle, and effective sleep protocol. CONCLUSIONS: In this concept mapping study, ICU professionals provided strategies that spanned a number of conceptual implementation clusters. Results can be used by ICU leaders for implementation planning to address context-specific interdisciplinary approaches to improve ABCDEF bundle implementation

Pneumothorax in COVID-19 Acute Respiratory Distress Syndrome: Case Series.

Objective The study aims to describe the clinical characteristics and outcomes of patients with COVID-19 related acute respiratory distress syndrome (ARDS) who developed pneumothorax. Design and setting A retrospective chart review was performed of the electronic medical record. Patients were included if they were identified as having confirmed COVID-19 as well as pneumothorax from March 16, 2020 to May 31, 2020. Patients\u27 demographic and clinical characteristics, mechanical ventilator parameters, lung compliance measurements and outcomes during hospitalization were collected. This case series was conducted in intensive care units at two large tertiary care centers within the Northwell Health System, located in New York State. Patients A total of 75 patients were identified who were predominantly male (73.3%) with an average age of 62.8 years. Thirty (40%) were Hispanic, 20 (26.7%) were White, 16 (21.3%) were Asian, and nine (12%) were Black. Common comorbid conditions were hypertension (52%), diabetes mellitus (26.7%), hyperlipidemia (32.0%), and chronic pulmonary disease (8, 10.7%). Measurements and main results Most of the patients were diagnosed with pneumothorax while on mechanical ventilation (92%) despite overall adherence with lung-protective ventilation strategies. Average tidal volume was 6.66 mL/kg) of ideal body weight. The average positive end-expiratory pressure (PEEP) was 10.83 (cm) H2O. Lung compliance was poor, with average peak and plateau pressures of 41.9 cm H2O and 35.2 cm H2O, respectively. Inpatient mortality was high in these patients (76%). Conservative management with initial observation had a success rate (73.3%) with similar mortality and shorter length of stay (LOS) on average. Significant factors in the conservatively managed group included lack of tension physiology, the smaller size of pneumothorax, lack of underlying diabetes, presence of pneumomediastinum, and not being on mechanical ventilation during diagnosis. Conclusion Despite overall adherence to best practice ventilator management in ARDS, we observed a large number of pneumothoraces during the COVID-19 pandemic. Conservative management may be appropriate if there are no clinical signs or symptoms of tension physiology and pneumothorax size is small

Spontaneous mode non-invasive ventilation fails to treat respiratory failure in a patient with Multi-mincore disease: a case report

The increased morbidity and mortality resulting from respiratory failure in patients with neuromuscular disorders and/or kyphoscoliosis can be reversed with non-invasive ventilation. Spontaneous mode bilevel pressure ventilation is preferred to other modes of ventilation, due to relative ease of use, but may not be suitable for all patients. We report a 27-year old woman with Multi-minicore disease whose respiratory failure was refractory to spontaneous mode bilevel pressure ventilation. When we altered settings and provided mandatory inspiratory rise time and respiratory rate, it augmented her respiratory efforts and improved ventilation. Our case report describes the benefit of individualising non-invasive ventilation in the management of respiratory failure due to neuromuscular weakness and kyphoscoliosis

The effectiveness and safety of neurally adjusted ventilatory assist iviechanical ventilation compared to pressure support ventilation in optimizing patient venfilator synchrony in critically ill patients: a systematic review and meta-analysis

Background: Patient ventilator dyssynchrony is a physical characteristic of suboptimal interaction between patient and ventilator. Some primary clinical studies using neurally adjusted ventilatory assist compared to pressure support suggest it improves patient ventilator synchrony and reduces hospital mortality. With conflicting study outcomes, a systematic review of the effectiveness and safety of neutrally adjusted ventilatory assist is warranted. Objectives: This systematic review aimed to evaluate the effectiveness of neutrally adjusted ventilatory assist (NAVA) compared to pressure support ventilation (PSV) in optimizing patient ventilator synchrony in critically ill adult patients in intensive care unit (ICU). Methods: Seven databases ; the Cochrane Central Register of Controlled Trials, MEDLINE (PubMed), EMBASE, SCOPUS, ClinicalTrials.gov, Web of Science and CINAHL were searched using the following terms: neurally adjusted ventilatory assist, NAVA, neural trigger, interactive ventilatory support, respiration, artificial, mechanical ventilation, patient ventilator asynchrony, synchrony, asynchrony, dyssynchrony. The last search was conducted in April 2018. This review included studies that evaluated the use of NAVA compared with PSV in adult patients who required invasively mechanical ventilation. Outcomes of interest included the frequency of patient ventilator dyssynchrony (PVD) and mortality from all causes. The methodological quality of included studies was assessed, and the data were extracted by using standard forms. Standardized mean differences (SMDs) were calculated for continuous data and risk ratios for dichotomous data, both with 95% CIs. Results: A total of 1,078 articles were identified, for which 210 full text articles were reviewed. In total 17 studies met inclusion criteria. The outcome data were available for approximately 90% of participant (n=398). Neurally adjusted ventilatory assist significantly reduced the AI% by nearly one half of standard deviation; SMD 0.401, 95% CI 0.223 to 0.57, p value 0.000 and I2 0.00% (fixed effect model; two RCTs,128 participants). It was maintained in crossover study group ; SMD 0.304, 95% CI: 0.079 to 0.528, p value 0.008 and I2 75.85% (random effects model, 13 crossover studies, 347 participants). The reduction of the AI% estimated effect size was found to be larger in a sedated group; SMD 0.413, 95% CI: 0.125 to 0.702, p value 0.005 and I2 71.24% than a non-sedated group; SMD 0.225, 95% CI: - 0.208 to 0.659, p value 0.308 and I2 86.76% (random effects model, 10 studies, 248 participants). In addition, a higher reduction of AI% effect size was found in a treatment duration longer than an hour group; SMD 0.413, 95% CI:0.044 to 0.782, p value 0.028 and I2 0.00% than a shorter than an hour group; SMD 0.287, 95% CI:0.069 to 0.505, p value 0.010 and I2 77.62% ( random effects model, 13 studies,301 participants). Similarly, in a 20- minute and longer PVD event-measurement time group found that NAVA reduced AI% more than in a shorter than 20-minute PVD event -measurement time group; SMD 0.389, 95% CI: 0.109 to 0.668, p value 0.006 and I2 0.00% and SMD 0.267, 95% CI: 0.024 to 0.510, p value 0.031 and I2 82.18%, respectively ( random effects model, 13 studies, 301 participants). Neurally adjusted ventilatory assist was associated with a reduction of the risk of AI>10%; OR 0.688,95% CI:0.514 to 0.921, p value 0.012 and I2 21.93%). It significantly reduced the NeuroSync index; SMD 0.745, 95% CI:0.316 to 1.175, p value 0.001 and I2 0.00% (fixed effect model, two studies, 24 participants). In addition, patients in the NAVA group had a lower patient ventilator asynchrony % than in the PSV group in both two levels of assistance; NAVA-low and NAVA-high (Mean ± SD) 7±2% and 7±2%; PSV-low and PSV-high 18±13% and 23±12%, respectively. Patient ventilated with NAVA had a lower ICU mortality compared to the PSV; OR 0.610, 95% CI:0.263 to 1.418, p value 0.251 and I2 0.00% (fixed effect model, two RCTs, 153 participants). Conclusion: Neurally adjusted ventilatory assist is associated with a reduction of PVD frequency compared with PSV. However, effect on lowering the ICU mortality rate is uncertain.Thesis (MClinSc) -- University of Adelaide, The Joanna Briggs Institute, 201

Automated detection and quantification of reverse triggering effort under mechanical ventilation

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. 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. 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 cmH0, with a median of 8.7 cmH0. RT with breath stacking had the highest levels of Pmus, and RTs with no breath stacking were of similar magnitude than pressure support breaths. An automated detection tool using airway pressure and flow can diagnose reverse triggering with excellent accuracy. RT generates a median Pmus of 9 cmHO with important variability between and within patients. BEARDS, NCT03447288

Invasive Mechanical Ventilation of COVID-19 ARDS Patients

The purpose of this review article is to analyse evidence on the use of ventilatory strategies and associated cointerventions in adult patients with COVID-19 induced acute respiratory distress syndrome (ARDS) and to provide treatment recommendations based on these interventions. For each recommendation mentioned, it is important to consider the quality of the evidence reviews thoroughly before applying these recommendations to specific clinical situations or policy decisions. No guideline or recommendations can consider all the compelling clinical features of individual patients, as they are unique. Thus, it is imperative that clinicians, patients, policy makers, and other stakeholders should not regard these recommendations as mandatory. However, this review article, impartially discusses the nuances of treatment available and management protocols followed in many centres around the world for the consumption of all treating physicians.El propósito de este artículo de revisión es analizar la evidencia sobre el uso de estrategias ventilatorias y cointervenciones asociadas en pacientes adultos con síndrome de dificultad respiratoria aguda (SDRA) inducido por COVID-19 y brindar recomendaciones de tratamiento basadas en estas intervenciones. Para cada recomendación mencionada, es importante considerar la calidad de las revisiones de la evidencia a fondo antes de aplicar estas recomendaciones a situaciones clínicas específicas o decisiones políticas. Ninguna guía o recomendación puede considerar todas las características clínicas convincentes de los pacientes individuales, ya que son únicas. Por lo tanto, es imperativo que los médicos, los pacientes, los responsables políticos y otras partes interesadas no consideren estas recomendaciones como obligatorias. Sin embargo, este artículo de revisión analiza de manera imparcial los matices del tratamiento disponible y los protocolos de manejo seguidos en muchos centros alrededor del mundo para el consumo de todos los médicos tratantes