patient – ventilator asynchrony dr vincent ioos medical icu – pims apicon 2008 workshop on...
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Patient – Ventilator Asynchrony
Dr Vincent IoosMedical ICU – PIMS
APICON 2008Workshop on Mechanical
Ventilation
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Goal of mechanical ventilation
• Do you mechanically ventilate your patient to reverse diaphragmatic fatigue ?
or • Do you encourage greater diaphragm use
to avoid ventilator-induced diaphragmatic dysfunction?
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Patient triggered ventilation
• Assisted mechanical ventilation• Avoid ventilator induced diaphragmatic
dysfunction• Providing sufficient level of ventilatory
support to reduce patient’s work of breathing
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Volume or pressure oriented?
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Volume oriented modes
• Inspiratory flow is preset
• Inspiratory time determines the Vt
• The variable parameter is the airway peak and plateau pressure
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Equation of insuflated gasesin flow assist control
ventilation
• Describes interactions between the patient and the ventilator
• Pressure required to deliver a volume of gas in the lungs is determined by elastic and resistive properties of the lung
Paw = Vt/C +VR + PEP
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Airway Pressure
C = Vt / P and P = P Plat - PEEP
Paw= Po + Vt/C + RV
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Flow shapes
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Pressure oriented modes
• Pressure in airway is the preset parameter
• Flow is adjusted at every moment to reach the preset pressure
• The variable parameter is Vt
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Equation of motionin pressure support ventilation
• Pressure = pressure applied by the ventilator on the airway + pressure generated by respiratory muscles
• Pmus is determined by respiratory drive and respiratory muscle strenght
Paw + Pmus = Vt/C + VxR + PEP
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Determinant factors of inspiratory flow in PSV
• Pressure support setting• Pmus (inspiratory effort)• Airway resistance• Respiratory system compliance• Vt directly depends on inspiratory flow,
but also on auto-PEEP (decreases the driving pressure gradient)
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Look at the curves !
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A challenge for the intensivist
• Discomfort anxiety • Increased work of breathing• Increased requirement of sedation• Increased length of mechanical ventilation• Increased incidence of VAP
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Patient-ventilator asynchrony
• Mechanical ventilation: 2 pumps– Ventilator controlled by the physician– Patient’s own respiratory muscle pump
• Mismatch between the patient and the ventilator inspiratory and expiratory time time
• Patient « fighting » with the ventilator
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Ventilation phases
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Trigger asynchrony
• Ineffective triggerring: muscular effort without ventilator trigger
• Double triggerring• Auto-triggering• Insensitive trigger: triggering that
requires excessive patient effort
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Ineffective triggering
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Double triggering
• Cough
• Sighs
• Inedaquate flow delivery
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Auto-triggering
• Circuit leak• Water in the circuit• Cardiac oscillations• Nebulizer treatments• Negative suction applied trough chest
tube
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Flow asynchrony
• Fixed flow pattern (volume oriented)• Variable flow pattern (pressure oriented)
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Volume oriented ventilation (fixed flow pattern)
• Inspiratory flow varies according to the underlying condition
• If patient’s flow demand increases, peak flow should be adjusted accordingly
• Usually, peak flow is too low• Dished-out appearance of the presure-
wave-form• Importance of flow-pattern
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-Ineffictive triggering at 30 l/mn
- Increase in flow rate
- Subsequent increase of expiratory time
- Decreased dynamic hyperinflation
- Subsequent decrease in ineffictive trigerring
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Importance of flow pattern
Increase in peak-flow setting fron 60 to 120 l/mn eliminated scooped
appearance of the airway pressure waveform
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Pressure oriented ventilation (variable flow)
• Peak flow is depending on :– Set target pressure– Patient effort– Respiratory system compliance
• Adjustement : rate of valve opening = rise time = presure slope = flow acceleration
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Termination asynchrony
• Ventilator should cycle at the end of the neural inspiration time
• Delayed termination: – Dynamic hyperinflation– Trigger delay– Ineffective triggering
• Premature termination
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Set inspiratory time < 1 sec
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PSV = 10 cmH2O
Inspiratoy flow terminate despite continued Pes defelection
Double Trigerring
Patient 1 Patient 2
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Expiratory asynchrony
• Shortened expiratory time: Auto-PEEP trigger asynchrony
– Delay in the relaxation of the expiratory muscle activity prior to the next mechanical inspiration
– Overlap between expiratory and insiratory uscle activity
• Prolonged expiratory time
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Auto-PEEP created by flow patterns that increases
inspiratory time • Lower peak flow during control
ventilation• Switch from constant flow to descending
ramp flow• Inadequate pressure slope during presure
controlled ventilation• Termination criteria that prolong
expiratory time during PSV
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Conclusion
• Look at your patient !• Look at the curves !• Have a good knowledge of the ventilation
modalities of the ventilator you are using• Excessive ventilatory support leads to
ineffective triggering• Do not forget to set trigger sensitivity, to
avoid excessive effort and auto-triggering