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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

Servo I

EngströmGalileo

Evita 4

Extend

Avea

PB 840

Pressure support ventilation

Pes

Paw

Good Synchrony: Paw follows Pes

time