Patient ventilator interactions during mechanical ventilation

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Patient Ventilator Interaction during Mechanical Ventilation lecture presented by Dr.Lluis Blanch at Pulmonary Critical Care Egypt Meeting and Exhibition, January 2014. www.pccmegypt.com

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Patient ventilator interactions during mechanical ventilation

  1. 1. Patient Ventilator Interaction during MV Lluis Blanch MD, PhD Senior Critical Care Department Director Research and Innovation Corporació Sanitaria Parc Tauli. Sabadell. Spain. Universitat Autònoma de Barcelona. Spain. 22-23 January 2014 Cairo, Egypt
  2. 2. Dissynchrony between Patient & Ventilator diaphoresis & nasal flaring sternomastoid activity cyanosis tachypnea supresternal & supraclavicular recession abdominal paradox intercostal recession tachycardia Tobin MJ. Principles and Practice of MV. 1994.
  3. 3. Patient & Ventilator-Related Factors that Affect Patient-Ventilator Interaction • Patient related factors – Respiratory center output – Respiratory system mechanics – Disease states & conditions – Artificial airway in place • Ventilator related factors – Triggering – Cycling off – Ventilator causes of patient agitation – Dead space
  4. 4. Types of dyssynchronies Trigger dyssynchrony trigger delay autotrigger inefective inspitarory effort insufficient airflow Cycling off dyssynchrony short cycle prolonged cycle double trigger
  5. 5. Pressure Support Ventilation. AutoPEEP ECG CO2 . V Paw VT
  6. 6. Ineffective Inspiratory Efforts During Expiration Descriptive tracings ALI Patient Q Paw V Corretger E, Murias G,… Blanch L. Med Intensiva (2011 Oct 17)
  7. 7. PSV: Ineffective Efforts Flow (L/s) Can occur when: - too much PSV Paw -presence of autoPEEP (cmH2O) -inadequate triggering Pes (cmH2O) Time (s) Brochard L. Principles & Practice of Mechanical Ventilation. Tobin M, ed. 2007
  8. 8. PSV from 20 to 13 cmH2O Cycling off 45%
  9. 9. Patient-ventilator asynchronies: role of PSV level & flow triggering Georgopoulos D et al Intensive Care Medicine 2006; 32:34-47
  10. 10. Double triggering VCV PCV Double triggering occurs when the ventilator inspiratory time is shorter than the patient’s inspiratory time Corretger E, Murias G,… Blanch L. Med Intensiva ((2011 Oct 17)
  11. 11. Assist Control Ventilation. Double Cycling ECG CO2 . V Paw VT
  12. 12. Crit Care Med 2008; 36:3019–3023 Median & IQR of stacked breaths per minute for each patient. Breath stacking occurs frequently. Set TV in mL/kg PBW has a strong association with the frequency of breath stacking.
  13. 13. Crit Care Med 2013;41:2177-87 30 pts with breath stacking: No Intervention Increase Sedation/Analgesia Ventilator Adjustment
  14. 14. Crit Care Med 2013;41:2177-87 Change in Ventilator: Increase Ti or Use PSV
  15. 15. Crit Care Med 2013;41:2177-87 Increase Ti from 0.4 s to 1 s IEE
  16. 16. Mechanical Ventilation-Induced Reverse-Triggered Breaths Reverse triggering & Respiratory Entrainment Stretch receptors & vagal C fibers are responsible for the Hering-Breuer reflexes Akoumianaki E et al. Chest 2013;143:927-38.
  17. 17. Short cycle is a cycle in which the inspiratory time is less than half the mean inspiratory time. Airflow Airway Pressure Volume
  18. 18. Prolonged cycle is a cycle in which the inspiratory time is more than twice the mean inspiratory time Airflow Airway Pressure Volume
  19. 19. PSV: Prolonged Inspiration Flow (L/s) Results from a failure to recognize flow cyclingPaw (cmH2O) off criterion. Timax Can occur when: - end-inspiratory leak Pes (cmH2O) - wrong cycling off Time (s) Brochard L. Principles & Practice of Mechanical Ventilation. Tobin M, ed. 2007
  20. 20. Pressure support ventilation Ti/Ttot during MV Pes 1s CO2 . V Paw 1s 0.7s
  21. 21. Terminal Dyssyncrony Ti patient > Ti ventilator (PSV)
  22. 22. Terminal Dyssyncrony COPD & PSV Expiratory muscle activation Parthasarathy S et al. Am J Respir Crit Care Med 1998;158:1471-78.
  23. 23. Secretions Airflow Airway Pressure Volume
  24. 24. Two type breaths: mandatory SIMV breaths are volumecontrolled (600 mL) and flow-targeted (50 L/min). The nonmandatory breaths are PS (15 cmH2O) with cycling off of 25% de Wit.Respir Care 2011;56(1):61– 68.
  25. 25. J Crit Care. 2009 March ; 24(1): 74–80 In 20 ICU patients airway pressure and airflow were recorded for 15 minutes. Patient ventilator asynchrony was assessed by determining the number of breaths demonstrating ineffective triggering, double triggering, short cycling, and prolonged cycling. ITI= ineffectively triggered breaths total number breaths For one unit decrease in RASS, ITI increased by 2.7%, p = 0.04
  26. 26. Intensive Care Med. 2006 Oct;32(10):1515-22.
  27. 27. Crit Care Med 2009; 37:2740–2745 6 patients had pressure and flow-time waveforms recorded for 10 mins within the first 24 hrs of MV initiation. Ineffective triggering index (ITI) was calculated by dividing the number of ineffectively triggered breaths by the total number of breaths (triggered and ineffectively triggered).
  28. 28. Crit Care Med 2009; 37:2740–2745
  29. 29. 60 patients included, 55% of whom were hypercapnic and monitored for 30 minutes.
  30. 30. 1. Auto-triggering was present in 8 (13%) patients, double triggering in 9 (15%), ineffectiv breaths in 8 (13%), premature cycling 7 (12%) and late cycling in 14 (23%). 2. An asynchrony index (AI) >10%, indicating severe asynchrony, was present in 26 patients (43%). 3. Multivariate analysis showed that the level of pressure support (OR: 1.32 per additional cmH2O of pressure support, 95% CI: 1.10–1.58; P = 0.003) and the magnitude of leak (OR: 1.24 per additional l/min of leak, 95% CI: 1.03–1.48; P = 0.019) were associated with the presence of an AI >10%.
  31. 31. Crit Care Med 2011 Vol. 39, No. 11 Breath Analysis: Paw & Flow waveforms N-Ex: Non experts (first year residents) Ex: Experts (ICU physicians) Report Analysis: Paw & Flow & EADi waveforms 3731 PS breaths evaluated Visual inspection of flow and airway pressure waveforms provides a gross estimate of patient–ventilator synchrony
  32. 32. Nurse detection of ineffective inspiratory efforts during mechanical ventilation Chacon E et al. Am J Crit Care. 2012 Jul;21(4):e89-93 Nurse 1 (n=985): SS 93 %; SP 98 %. Kappa index 0.92 (95%CI: 0.89-0.94). Nurse 2 (n=970): SS 99 %; SP 85 %. Kappa index 0.74 (95%CI: 0.70-0.78).
  33. 33. Validation of the Better Care® system to detect ineffective efforts during expiration (IEE) in MV patients: A Pilot Study. Experts Opinion EAdi Validation 8 patients; 1024 breaths 8 patients; 9600 breaths Blanch L et al. Intensive Care Med 2012 (DOI 10.1007/s00134-012-2493-4)
  34. 34. Validation of the Better Care® system to detect ineffective efforts during expiration (IEE) in MV patients: A Pilot Study. IEE Compared with the EAdi, the IEE algorithm had a SS of 65.2%, SP 99.3%, PPV 90.8%, NPV 96.5%, and Kappa index 73.9% Blanch L et al. Intensive Care Med 2012 (DOI 10.1007/s00134-012-2493-4)
  35. 35. Patient & Waveforms & Advanced Alarms
  36. 36. Neurophysiologic Model of Respiratory Discomfort: Air Hunger Work/Effort Tightness O’Donnell DE et al Resp Physiol Neurobiol 2009
  37. 37. J Neurophysiol 2002;88:1500-1511 Air Hunger Increases MRI Signal in Insula (Limbic System) Insula (Limbic System): -Perception of dyspnea, hunger, thirst -Afferents of resp. chemoreceptors -Stretch receptors project to insula -Seat of emotions -Large role in memory Insula Air hunger may cause severe psychological trauma
  38. 38. Crit Care Med 2011;39:2059-65 45 patients (47%) reported dyspnea (respiratory effort in seven cases, air hunger in 15, both in 16, and neither of these in seven). Dyspneic and nondyspneic patients did not differ in terms of age, SAPS II or indication for MV. Dyspnea was significantly associated with anxiety (OR, 8.84; 95%CI, 3.26 –24.0), assistcontrol ventilation (OR, 4.77; 95% CI, 1.60–4.3), and heart rate (OR, 1.33 per 10 beats/min; 95% CI, 1.02–1.75).
  39. 39. Physiologic Events During MV Discomfort Dyspnea - Air Hunger - Work/Effort - Tightness Agitation Risk of Extubation Hours
  40. 40. The World of Asynchronies during invasive MV RESPIRATORY CARE • JUNE 2013 VOL 58 NO 6 Am J Respir Crit Care Med Vol 188, pp 1058–1068, Nov 1, 2013 Minerva Anestesiol 2013;79:434-44
  41. 41. Project of Intelligent Alarms during MV Sabadell 5 July 2012
  42. 42. lblanch@tauli.cat Thanks !!

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