Patient Ventilator Asynchrony

Dr Vincent Ioos
Medical ICU PIMS
APICON 2008
Workshop on Mechanical Ventilation
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?
Patient triggered ventilation
Assisted mechanical ventilation
Avoid ventilator induced diaphragmatic
dysfunction
Providing sufficient level of ventilatory support
to reduce patients work of breathing
Volume or pressure oriented?
Volume oriented modes
Inspiratory flow is preset

Inspiratory time determines the Vt

The variable parameter is the airway peak and
plateau pressure
Equation of insuflated gases
in 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
Airway Pressure
C = Vt / P and P = P Plat - PEEP
Paw= Po + Vt/C + RV
Flow shapes
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


Equation of motion
in 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
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)
Look at the curves !
A challenge for the intensivist
Discomfort anxiety
Increased work of breathing
Increased requirement of sedation
Increased length of mechanical ventilation
Increased incidence of VAP


Patient-ventilator asynchrony
Mechanical ventilation: 2 pumps
Ventilator controlled by the physician
Patients own respiratory muscle pump

Mismatch between the patient and the ventilator
inspiratory and expiratory time time

Patient fighting with the ventilator

Ventilation phases
Trigger asynchrony
Ineffective triggerring: muscular effort without
ventilator trigger
Double triggerring
Auto-triggering
Insensitive trigger: triggering that requires
excessive patient effort

Ineffective triggering
Double triggering
Cough
Sighs
Inedaquate flow delivery

Auto-triggering
Circuit leak
Water in the circuit
Cardiac oscillations
Nebulizer treatments
Negative suction applied trough chest tube

Flow asynchrony
Fixed flow pattern (volume oriented)
Variable flow pattern (pressure oriented)

Volume oriented ventilation
(fixed flow pattern)
Inspiratory flow varies according to the
underlying condition
If patients 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
-Ineffictive triggering at
30 l/mn
- Increase in flow rate
- Subsequent increase of
expiratory time
- Decreased dynamic
hyperinflation
- Subsequent decrease
in ineffictive trigerring

Importance of flow pattern
Increase in peak-flow setting fron 60 to 120
l/mn eliminated scooped appearance of the
airway pressure waveform
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

Termination asynchrony
Ventilator should cycle at the end of the neural
inspiration time

Delayed termination:
Dynamic hyperinflation
Trigger delay
Ineffective triggering

Premature termination
Set inspiratory time < 1 sec
PSV = 10 cmH2O
Inspiratoy flow terminate despite
continued Pes defelection
Double Trigerring
Patient 1 Patient 2
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
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

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