Potentially harmful effects of inspiratory synchronization during pressure preset ventilation
J. C. M. Richard| A. Lyazidi| E. Akoumianaki| S. Mortaza| R. L. Cordioli| J. C. Lefebvre| N. Rey| L. Piquilloud| G. F. Sferrazza-Papa| A. Mercat| L. Brochard
Original
Volume 39,
Issue
11
/
November ,
2013
Pages 2003 - 2010
Abstract
Purpose
Pressure preset ventilation (PPV) modes with set inspiratory time can be classified according to their ability to synchronize pressure delivery with patient’s inspiratory efforts (i-synchronization). Non-i-synchronized (like airway pressure release ventilation, APRV), partially i-synchronized (like biphasic airway pressure), and fully i-synchronized modes (like assist-pressure control) can be distinguished. Under identical ventilatory settings across PPV modes, the degree of i-synchronization may affect tidal volume (VT), transpulmonary pressure (PTP), and their variability. We performed bench and clinical studies.
Methods
In the bench study, all the PPV modes of five ventilators were tested with an active lung simulator. Spontaneous efforts of −10 cmH2O at rates of 20 and 30 breaths/min were simulated. Ventilator settings were high pressure 30 cmH2O, positive end-expiratory pressure (PEEP) 15 cmH2O, frequency 15 breaths/min, and inspiratory to expiratory ratios (I:E) 1:3 and 3:1. In the clinical studies, data from eight intubated patients suffering from acute respiratory distress syndrome (ARDS) and ventilated with APRV were compared to the bench tests. In four additional ARDS patients, each of the PPV modes was compared.
Results
As the degree of i-synchronization among the different PPV modes increased, mean VT and PTP swings markedly increased while breathing variability decreased. This was consistent with clinical comparison in four ARDS patients. Observational results in eight ARDS patients show low VT and a high variability with APRV.
Conclusion
Despite identical ventilator settings, the different PPV modes lead to substantial differences in VT, PTP, and breathing variability in the presence spontaneous efforts. Clinicians should be aware of the possible harmful effects of i-synchronization especially when high VT is undesirable.
Keywords
References
- The Acute Respiratory Distress Syndrome Network (2000) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 342:1301–1308
- Amato MB, Barbas CS, Medeiros DM, Magaldi RB et al (1998) Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med 338:347–354
- Slutsky AS, Tremblay LN (1998) Multiple system organ failure. Is mechanical ventilation a contributing factor? Am J Respir Crit Care Med 157:1721–1725
- Gattinoni L, Protti A, Caironi P, Carlesso E (2010) Ventilator-induced lung injury: the anatomical and physiological framework. Crit Care Med 38:S539–S548
- Papazian L, Forel JM, Gacouin A, Penot-Ragon C et al (2010) Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med 363:1107–1116
- Putensen C, Mutz NJ, Putensen-Himmer G, Zinserling J (1999) Spontaneous breathing during ventilatory support improves ventilation-perfusion distributions in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 159:1241–1248
- Putensen C, Zech S, Wrigge H, Zinserling J, Stuber F, Von Spiegel T, Mutz N (2001) Long-term effects of spontaneous breathing during ventilatory support in patients with acute lung injury. Am J Respir Crit Care Med 164:43–49
- Marini JJ (2012) Spontaneously regulated vs. controlled ventilation of acute lung injury/acute respiratory distress syndrome. Curr Opin Crit Care 17:24–29
- Neumann P, Wrigge H, Zinserling J, Hinz J et al (2005) Spontaneous breathing affects the spatial ventilation and perfusion distribution during mechanical ventilatory support. Crit Care Med 33:1090–1095
- Wrigge H, Zinserling J, Neumann P, Muders T, Magnusson A, Putensen C, Hedenstierna G (2005) Spontaneous breathing with airway pressure release ventilation favors ventilation in dependent lung regions and counters cyclic alveolar collapse in oleic-acid-induced lung injury: a randomized controlled computed tomography trial. Crit Care 9:R780–R789
- Rose L, Hawkins M (2008) Airway pressure release ventilation and biphasic positive airway pressure: a systematic review of definitional criteria. Intensive Care Med 34:1766–1773
- Sasidhar M, Chatburn RL (2012) Tidal volume variability during airway pressure release ventilation: case summary and theoretical analysis. Respir Care 57:1325–1333
- Akoumianaki E, Rey N, Lyazidi A, Perez-Martinez N, Brochard L, Richard JCM (2012) Impact of airway pressure release ventilation (APRV) and biphasic intermittent positive airway pressure (BIPAP) modes on the lung protection in breathing lung model. Intensive Care Med 38(Suppl 1):S142
- Sessler CN, Gosnell MS, Grap MJ, Brophy GM et al (2002) The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 166:1338–1344
- Daoud EG, Farag HL, Chatburn RL (2012) Airway pressure release ventilation: what do we know? Respir Care 57:282–292
- Modrykamien A, Chatburn RL, Ashton RW (2011) Airway pressure release ventilation: an alternative mode of mechanical ventilation in acute respiratory distress syndrome. Cleve Clin J Med 78:101–110
- Chiumello D, Carlesso E, Cadringher P, Caironi P et al (2008) Lung stress and strain during mechanical ventilation for acute respiratory distress syndrome. Am J Respir Crit Care Med 178:346–355
- González M, Arroliga AC, Frutos-Vivar F, Raymondos K et al (2010) Airway pressure release ventilation versus assist-control ventilation: a comparative propensity score and international cohort study. Intensive Care Med 36:817–827
- Maxwell RA, Green JM, Waldrop J, Dart BW et al (2010) A randomized prospective trial of airway pressure release ventilation and low tidal volume ventilation in adult trauma patients with acute respiratory failure. J Trauma 69:501–510 discussion 511
- Richard JC, Maggiore SM, Jonson B, Mancebo J, Lemaire F, Brochard L (2001) Influence of tidal volume on alveolar recruitment. Respective role of PEEP and a recruitment maneuver. Am J Respir Crit Care Med 163:1609–1613
- Cereda M, Foti G, Musch G, Sparacino ME, Pesenti A (1996) Positive end-expiratory pressure prevents the loss of respiratory compliance during low tidal volume ventilation in acute lung injury patients. Chest 109:480–485
- Pelosi P, Cadringher P, Bottino N, Panigada M et al (1999) Sigh in acute respiratory distress syndrome. Am J Respir Crit Care Med 159:872–880
- Muscedere JG, Mullen JB, Gan K, Slutsky AS (1994) Tidal ventilation at low airway pressures can augment lung injury. Am J Respir Crit Care Med 149:1327–1334
- Richard JC, Brochard L, Vandelet P, Breton L et al (2003) Respective effects of end-expiratory and end-inspiratory pressures on alveolar recruitment in acute lung injury. Crit Care Med 31:89–92
- Grasso S, Mascia L, Del Turco M, Malacarne P et al (2002) Effects of recruiting maneuvers in patients with acute respiratory distress syndrome ventilated with protective ventilatory strategy. Anesthesiology 96:795–802
- Suki B, Alencar AM, Sujeer MK, Lutchen KR et al (1998) Life-support system benefits from noise. Nature 393:127–128
- Ma B, Suki B, Bates JH (2011) Effects of recruitment/derecruitment dynamics on the efficacy of variable ventilation. J Appl Physiol 110:1319–1326
- Thille AW, Lyazidi A, Richard JC, Galia F, Brochard L (2009) A bench study of intensive-care-unit ventilators: new versus old and turbine-based versus compressed gas-based ventilators. Intensive Care Med 35:1368–1376
- Lyazidi A, Thille AW, Carteaux G, Galia F, Brochard L, Richard JC (2010) Bench test evaluation of volume delivered by modern ICU ventilators during volume-controlled ventilation. Intensive Care Med 36:2074–2080