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Patient-Ventilator Dyssynchrony
Laurent Brochard
Conflicts of interest
• Research grant: Covidien Medtronic
• Research grant & equipment: Fisher Paykel
• Equipment: Maquet
• Equipment: Philips
• Equipment & patent with Universities: General Electric
• Research grant & equipment: Air Liquide
ICM 2006
ICM 2017
Events of IEs were defined as periods of time containing more than 30 IEs in a
3-min period (50% for RR 20/min).
What dose of ventilation?D
ysf
un
ctio
n
Dose of Ventilatory Support
Respiratory
Distress
VILI
VALI
VIDD
Normal
WOB
Patient-
Ventilator
Asynchrony
Patient-
Ventilator
Asynchrony
Excessive
sedation?
Assistance in excess
• Apneas
• Ineffective Efforts or Missed Cycles
Pressure support ventilation
1 min Parthasarathy. AJRCCM 2002;166:1423
C4-A1
O3-A2
ROC
LOC
Chin
Leg
VT
RC
ABSpO2
EKG
Assist-Control Pressure SupportArousal
Assist-Control, PEEP 10 cmH2O
Triggering asynchronyChao et al., Chest 1997; 112: 1592-1599
Assist-control, ø PEEP
-2
0
2
4
6
0 2 4 6 8
Wasted Effort: Ineffective breath
Esophageal
Pressure
(cmH2O)
0
5
10
15
20
25
Airway
Pressure
(cmH2O)
-0.6
-0.4
-0.2
0
0.2
0.4
0.6
0.8Pressure drop
Flow increase
Time (s)
Flow
(L/s)
Intrinsic
PEEP
Ineffective triggering
Start of patient’s effort
Start of ventilator insufflation
0
5
10
15
20
25
0 1 2 3
0
5
10
15
20
25
0 1 2
0
5
10
15
20
25
0 1 2 3
0
5
10
15
20
25
0 1 2
Airway Pressure (cmH2O)
Baseline PS-ZEEP
Baseline PS-PEEP
Optimal PS Optimal Ti
Time (s)
Intensive Care Med 2008
0
10
20
30
40
50
60
PS basal PS optimal
Asynchrony Index (%)
Baseline PS-PEEP
Optimal PS
Thille et al., Intensive Care Med 2008
Ineffective efforts – PS level
Thille AW et al. Intensive Care Med 2008;34:1477-1486
PS
level
(cm
H2O
)
CCM 2018
Insufficient Assistance
• Double triggering, breath stacking and short cycles
-5
0
5
10
0 2 4 6 8 10
-5
0
5
10
0 1 2 3
0
5
10
15
20
0 1 2 3
-0,8
-0,4
0
0,4
0,8
1,2
0 1 2 3
-0.8
-0.4
0
0.4
0.8
1.2
0 2 4 6 8 10
0
5
10
15
20
25
30
0 2 4 6 8 10
Flow
(L/min)
Airway
Pressure
(cmH2O)
Esophageal
Pressure
(cmH2O)
Beginning of patient’s effort
End of patient’s effort
Double Triggering
Continuation of
patient’s effort
Under Assistance
ACV
Excessive Sedation?
• Respiratory Entrainement or Reverse Triggering, breath stacking and short cycles
Paw (cm H2O)
Flow (L/sec)
EAdi (µV)
Accidental observation…
Akoumianaki E et al Chest 2012
Paw (cm H2O)
Flow (L/sec)
EAdi (µV)
Accidental observation…
Akoumianaki E et al Chest 2012
Flow
Paw
Pes
VT
Clinical consequences: VT increase
Clinical consequences: double cycle
Validation of an automated neural index to detect reverse triggering asynchrony in patients under mechanical ventilation.Ricard Mellado Artigas, Felipe Damiani, Thomas Piraino, Michela Rauseo, Ibrahim Soliman, Detajin Junhasavasdikul, Luana Melo, Lu Chen, Christer Sinderby, Norm Comtois, Leo Heunks, Laurent Brochard
Day 1 – 25 patients on Controlled (ACV) Ventilation
10/25 (40%) patients have > 10% RT
Clinical consequences of dyssynchronies
•Dynamic hyperinflation
•Excessive or insufficient ventilatory assistance
•2)
•1)
•3) •Inadequate sedation
•4)
•5) •Errors in assessing weaning readiness
•6) •Prolonged duration of ventilation
•Sleep fragmentation
•7) •Respiratory sequelae...
•8) •Mortality
APRIL 9-11, 2019
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ICU ventilators
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Extend
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Pes
Paw
Good Synchrony: Paw follows Pes
time