Background Intrinsic positive end-expiratory pressure (auto-PEEP) is a common problem in mechanically ventilated patients, which can lead to adverse effects on patients comfort, hemodynamics, lung mechanics and gas exchange. Triggering systems play a crucial role in the delivery of mechanical ventilation, and advancements in smart triggering technology aim to optimize patient-ventilator synchrony. This bench study aims to compare the performance of the novel SMART Trigger to traditional pressure and flow triggers in the context of auto-PEEP. Methods A lung model simulating severe obstructive pattern with high compliance (80 ml/cmH2O) and high resistance 30 cmH2O/L/s was connected to the Panther 5 ventilator (Origin Medical, California, USA). The mode was set at Volume Controlled with a tidal volume of 700 ml and mandatory breath per min (BPM) of 10/min and Inspiratory time of 2 seconds to intentionally create auto-PEEP. Simulated spontaneous breaths set at 20 BPM with increasing muscle pressure (Pmus) from -1 to maximum of -25 or till full trigger of all breaths. Three different triggering systems were evaluated: SMART Trigger (ST sensitivity 1 to 7), pressure trigger (-1 cmH2O), and flow trigger (1 l/min). The range of auto-PEEP levels induced increased incrementally with the increase in the respiratory rate ranging from 3 cmH2O for 10 BPM, 8 for 15 BPM, to 13 for 20 BPM. The following parameters were assessed for each triggering system: trigger sensitivity (defined as the number of breaths triggered above the mandatory breaths), and the trigger response time (time it takes from the beginning of muscle effort to the initiation of the breath. Results 100% of the breaths were triggered at Pmus (cmH2O) of -15 in the pressure trigger, -25 in flow trigger, -3 for ST1, -9 for ST2, -10 for ST3, -10 for ST4, -12 for ST5, -18 for ST 6, and -22 for ST 7. Trigger time (msec) for flow was 0.135 ± 0.02, for pressure 0.141 ± 0.04, for ST 1-4: 0.076 ± 0.03, for ST 5-7: 0.104 ± 0.04. Multivariate analysis of variance test showed significant difference between the time to trigger P <0.001. Conclusion This bench study highlights the potential advantages of SMART Trigger technology over conventional pressure and flow triggers during auto-PEEP. The SMART Trigger enhanced sensitivity and rapid response might contribute to improved patient-ventilator synchrony. Further research and clinical studies are warranted to validate these findings and explore the impact of smart trigger technology on patient outcomes in real-world scenarios. Keywords: SMART Trigger, Auto-PEEP, Trigger time
{"title":"SMART Trigger versus Flow and Pressure trigger performance during auto-PEEP","authors":"Bradley Fujiuchi, Ehab Daoud","doi":"10.53097/jmv.10083","DOIUrl":"https://doi.org/10.53097/jmv.10083","url":null,"abstract":"Background Intrinsic positive end-expiratory pressure (auto-PEEP) is a common problem in mechanically ventilated patients, which can lead to adverse effects on patients comfort, hemodynamics, lung mechanics and gas exchange. Triggering systems play a crucial role in the delivery of mechanical ventilation, and advancements in smart triggering technology aim to optimize patient-ventilator synchrony. This bench study aims to compare the performance of the novel SMART Trigger to traditional pressure and flow triggers in the context of auto-PEEP. Methods A lung model simulating severe obstructive pattern with high compliance (80 ml/cmH2O) and high resistance 30 cmH2O/L/s was connected to the Panther 5 ventilator (Origin Medical, California, USA). The mode was set at Volume Controlled with a tidal volume of 700 ml and mandatory breath per min (BPM) of 10/min and Inspiratory time of 2 seconds to intentionally create auto-PEEP. Simulated spontaneous breaths set at 20 BPM with increasing muscle pressure (Pmus) from -1 to maximum of -25 or till full trigger of all breaths. Three different triggering systems were evaluated: SMART Trigger (ST sensitivity 1 to 7), pressure trigger (-1 cmH2O), and flow trigger (1 l/min). The range of auto-PEEP levels induced increased incrementally with the increase in the respiratory rate ranging from 3 cmH2O for 10 BPM, 8 for 15 BPM, to 13 for 20 BPM. The following parameters were assessed for each triggering system: trigger sensitivity (defined as the number of breaths triggered above the mandatory breaths), and the trigger response time (time it takes from the beginning of muscle effort to the initiation of the breath. Results 100% of the breaths were triggered at Pmus (cmH2O) of -15 in the pressure trigger, -25 in flow trigger, -3 for ST1, -9 for ST2, -10 for ST3, -10 for ST4, -12 for ST5, -18 for ST 6, and -22 for ST 7. Trigger time (msec) for flow was 0.135 ± 0.02, for pressure 0.141 ± 0.04, for ST 1-4: 0.076 ± 0.03, for ST 5-7: 0.104 ± 0.04. Multivariate analysis of variance test showed significant difference between the time to trigger P <0.001. Conclusion This bench study highlights the potential advantages of SMART Trigger technology over conventional pressure and flow triggers during auto-PEEP. The SMART Trigger enhanced sensitivity and rapid response might contribute to improved patient-ventilator synchrony. Further research and clinical studies are warranted to validate these findings and explore the impact of smart trigger technology on patient outcomes in real-world scenarios. Keywords: SMART Trigger, Auto-PEEP, Trigger time","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42874311","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Mechanical ventilation is used to improve gas exchange and unload the respiratory muscles allowing for their rest and recovery, which require good synchronization between the patient and the ventilator. Spontaneous respiratory effort is generally preferred because it reduces atelectasis, improves oxygenation, and may prevent disuse diaphragm atrophy. Nevertheless, vigorous spontaneous effort can cause both lung injury and diaphragm injury (myotrauma). These injuries lead to prolonged ventilation, difficult weaning, and increased morbidity and mortality. Normal expiration is passive due to the recoil of the lungs and chest wall. In mechanical ventilation, during expiration the ventilator controls the pressure (ie, the target value is PEEP), therefore, we must look at the flow and volume waveforms to see the physiology and patient-ventilator interactions. In expiration the patient-ventilation interaction is not characterized by timing but by work. Expiratory effort (ie, negative Pmus) will deform the flow waveform in a negative direction (away from baseline). Keywords: synchronization, spontaneous effort, lung injury, myotrauma, expiratory effort
{"title":"Identifying asynchronies: Expiratory work","authors":"Victor Perez, Jamille Pasco","doi":"10.53097/jmv.10086","DOIUrl":"https://doi.org/10.53097/jmv.10086","url":null,"abstract":"Mechanical ventilation is used to improve gas exchange and unload the respiratory muscles allowing for their rest and recovery, which require good synchronization between the patient and the ventilator. Spontaneous respiratory effort is generally preferred because it reduces atelectasis, improves oxygenation, and may prevent disuse diaphragm atrophy. Nevertheless, vigorous spontaneous effort can cause both lung injury and diaphragm injury (myotrauma). These injuries lead to prolonged ventilation, difficult weaning, and increased morbidity and mortality. Normal expiration is passive due to the recoil of the lungs and chest wall. In mechanical ventilation, during expiration the ventilator controls the pressure (ie, the target value is PEEP), therefore, we must look at the flow and volume waveforms to see the physiology and patient-ventilator interactions. In expiration the patient-ventilation interaction is not characterized by timing but by work. Expiratory effort (ie, negative Pmus) will deform the flow waveform in a negative direction (away from baseline). Keywords: synchronization, spontaneous effort, lung injury, myotrauma, expiratory effort","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45915682","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background Emerging threat of drug resistance among Bacteria causing ventilator-associated pneumonia (VAP) has resulted in higher hospital costs, longer hospital stays, and increased hospital mortality. Biofilms in the endotracheal tube of ventilated patients act as protective shield from host immunity for bacterial growth and emerge them as multidrug resistant. Aim To know the prevalence of various bacterial isolates causing VAP, ability to form biofilm and their antibiotic susceptibility pattern. Material & Methods This study was conducted in the department of Microbiology in collaboration with the Respiratory Medicine department for a period of one year (November 2018-19). Endotracheal aspirate (ETA) along with 1 cm tube tip from clinically confirmed VAP patients were processed as per the standard microbiological procedure for the detection of bacterial biofilm formation and their antimicrobial resistance pattern. Statistical Analysis: Data was statistically evaluated using SPSS-PC-20 version. ‘P’ value less than 0.05, considered statistically significant. Results 72 patients with CPIS score > 6 were clinically confirmed as VAP. Various Bacteria isolated were Klebsiella pneumoniae in 52 (53%), Escherichia coli 16 (16.3%), Pseudomonas aeruginosa 14 (14.2%), Acinetobacter spp. 8 (8.1%), Proteus mirabilis 6 (6.1%) and Pseudomonas luteola 2 (2%). All bacterial isolates were processed for their ability to form biofilm, 86 (87.7%) were biofilm producers (BFP) while 12 (12.2%) were biofilm non-producers (BFNP). Conclusion Bacterial etiology, prolonged intubation, biofilm formation, and drug resistance have ramification on outcome of VAP. Keywords: Ventilator associated pneumonia (VAP), CPIS score, Biofilm formation, Tissue culture plate method (TCP), Antimicrobial drug resistance (AMR)
{"title":"Biofilm producer multi drug resistance alert bugs in ventilator associated pneumonia patients. Threat to antibiotic era and future concern","authors":"Karvi Agarwal, RK Verma, DP Singh, Sonal Jindal","doi":"10.53097/jmv.10082","DOIUrl":"https://doi.org/10.53097/jmv.10082","url":null,"abstract":"Background Emerging threat of drug resistance among Bacteria causing ventilator-associated pneumonia (VAP) has resulted in higher hospital costs, longer hospital stays, and increased hospital mortality. Biofilms in the endotracheal tube of ventilated patients act as protective shield from host immunity for bacterial growth and emerge them as multidrug resistant. Aim To know the prevalence of various bacterial isolates causing VAP, ability to form biofilm and their antibiotic susceptibility pattern. Material & Methods This study was conducted in the department of Microbiology in collaboration with the Respiratory Medicine department for a period of one year (November 2018-19). Endotracheal aspirate (ETA) along with 1 cm tube tip from clinically confirmed VAP patients were processed as per the standard microbiological procedure for the detection of bacterial biofilm formation and their antimicrobial resistance pattern. Statistical Analysis: Data was statistically evaluated using SPSS-PC-20 version. ‘P’ value less than 0.05, considered statistically significant. Results 72 patients with CPIS score > 6 were clinically confirmed as VAP. Various Bacteria isolated were Klebsiella pneumoniae in 52 (53%), Escherichia coli 16 (16.3%), Pseudomonas aeruginosa 14 (14.2%), Acinetobacter spp. 8 (8.1%), Proteus mirabilis 6 (6.1%) and Pseudomonas luteola 2 (2%). All bacterial isolates were processed for their ability to form biofilm, 86 (87.7%) were biofilm producers (BFP) while 12 (12.2%) were biofilm non-producers (BFNP). Conclusion Bacterial etiology, prolonged intubation, biofilm formation, and drug resistance have ramification on outcome of VAP. Keywords: Ventilator associated pneumonia (VAP), CPIS score, Biofilm formation, Tissue culture plate method (TCP), Antimicrobial drug resistance (AMR)","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48191922","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
This case report presents a rare case of a mechanical ventilation leak that was initially missed by clinicians in a patient with a myxoedema coma. Despite all efforts to investigate the causes of the leak, including a bedside lung ultrasound and chest radiograph, the leak persisted. It was eventually discovered that the rhythmic inflation and deflation of the polythene covering the closed suction system was causing the leak. The closed suction system was replaced with a new one, and the tidal volume was restored, resulting in the resolution of the leak alarm. The volume leak alarm and low volume alarm are important indicators of potential problems during mechanical ventilation, and close suction system malfunction is a potential cause of volume leak that should be considered in mechanically ventilated patients. Regular monitoring and appropriate management of these alarms and potential causes can help prevent complications and optimize patient care. Keywords: Mechanical ventilation, volume leak alarm, closed suction system, and myxoedema coma.
{"title":"The vanishing threat: Stealthy malfunction of closed suction system","authors":"Akshaya Das, Faisal Qureshi, Surinder Kumar, Nikhil Kothari","doi":"10.53097/jmv.10085","DOIUrl":"https://doi.org/10.53097/jmv.10085","url":null,"abstract":"This case report presents a rare case of a mechanical ventilation leak that was initially missed by clinicians in a patient with a myxoedema coma. Despite all efforts to investigate the causes of the leak, including a bedside lung ultrasound and chest radiograph, the leak persisted. It was eventually discovered that the rhythmic inflation and deflation of the polythene covering the closed suction system was causing the leak. The closed suction system was replaced with a new one, and the tidal volume was restored, resulting in the resolution of the leak alarm. The volume leak alarm and low volume alarm are important indicators of potential problems during mechanical ventilation, and close suction system malfunction is a potential cause of volume leak that should be considered in mechanically ventilated patients. Regular monitoring and appropriate management of these alarms and potential causes can help prevent complications and optimize patient care. Keywords: Mechanical ventilation, volume leak alarm, closed suction system, and myxoedema coma.","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42351121","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
This article highlights the significance of measuring plateau pressure in spontaneously breathing patients as it provides valuable information about PMI (Pmusc Index), which serves as a surrogate for the patient's efforts during mechanical ventilation. The PMI value obtained from the difference between the end-inspiratory occlusion plateau pressure and the airway pressure before the occlusion (PEEP + PS) enables clinicians to estimate the patient's inspiratory effort accurately. The accurate measurement of patient efforts is crucial in optimizing pressure support during lung protective weaning strategies. By titrating pressure support based on PMI values, clinicians can provide personalized care to patients, reducing the risk of ventilator-induced lung injury and enhancing the likelihood of successful weaning. Keywords: PMI, Pmus, Plateau pressure
{"title":"The forgotten tale of spontaneous plateau pressure","authors":"A. Anand","doi":"10.53097/jmv.10084","DOIUrl":"https://doi.org/10.53097/jmv.10084","url":null,"abstract":"This article highlights the significance of measuring plateau pressure in spontaneously breathing patients as it provides valuable information about PMI (Pmusc Index), which serves as a surrogate for the patient's efforts during mechanical ventilation. The PMI value obtained from the difference between the end-inspiratory occlusion plateau pressure and the airway pressure before the occlusion (PEEP + PS) enables clinicians to estimate the patient's inspiratory effort accurately. The accurate measurement of patient efforts is crucial in optimizing pressure support during lung protective weaning strategies. By titrating pressure support based on PMI values, clinicians can provide personalized care to patients, reducing the risk of ventilator-induced lung injury and enhancing the likelihood of successful weaning. Keywords: PMI, Pmus, Plateau pressure","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44560479","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Arthur Simonete, Natalia Alberti da Silva, C. Franck
Introduction The clinical evolution of severe burns can lead to Acute Respiratory Distress Syndrome (ARDS) with increased requirements for mechanical ventilation, which may lead to the development of Ventilator-Induced Lung Injury (VILI). Together, ARDS and VILI may cause irreversible lung damage. Mechanical power measures the amount of energy transferred from the ventilator to the respiratory system and is considered to be a unifying concept of the etiology VILI. However, doubts are still to be clarified. The goals of this study were to analyze pressure-controlled ventilation (PCV) in severe burn injury patients, to associate the mechanical power values over time with the outcome of burn patients (death or survival) and to associate the components of ventilation with the outcome of burn patients. Methods A longitudinal, observational and analytical study of 172 measurements of parameters collected daily from the ventilators of 26 severe burn patients undergoing mechanical ventilation with PCV. Statistical analysis was performed on the obtained values and the components of mechanical ventilation in relation to the outcome of the patients. Results The mechanical power calculated daily in burn patients was 22.83 ± SD joule per minute (J/min). Higher values of mechanical power were significantly related to the mortality (P 0.029) regardless of ventilation time, as well as higher values of PEEP, peak pressure, plateau pressure and driving pressure ( P <0.001), respiratory rate (P 0.01), variation of inspiratory pressure (P 0.03) and lower values of tidal volume (P 0.005). Conclusion In this analysis of mechanical ventilation, mean values of mechanical power in burn patients were elevated and that, regardless of mechanical ventilation time, these values are related to mortality, as well as higher values of pressures, driving pressure, respiratory rate and lower values of tidal volume, indicating the importance of stress frequency and propulsion force to overcome lung elastance.
{"title":"Analysis of mechanical power during pressure-controlled ventilation in patients with severe burns","authors":"Arthur Simonete, Natalia Alberti da Silva, C. Franck","doi":"10.53097/jmv.10076","DOIUrl":"https://doi.org/10.53097/jmv.10076","url":null,"abstract":"Introduction The clinical evolution of severe burns can lead to Acute Respiratory Distress Syndrome (ARDS) with increased requirements for mechanical ventilation, which may lead to the development of Ventilator-Induced Lung Injury (VILI). Together, ARDS and VILI may cause irreversible lung damage. Mechanical power measures the amount of energy transferred from the ventilator to the respiratory system and is considered to be a unifying concept of the etiology VILI. However, doubts are still to be clarified. The goals of this study were to analyze pressure-controlled ventilation (PCV) in severe burn injury patients, to associate the mechanical power values over time with the outcome of burn patients (death or survival) and to associate the components of ventilation with the outcome of burn patients. Methods A longitudinal, observational and analytical study of 172 measurements of parameters collected daily from the ventilators of 26 severe burn patients undergoing mechanical ventilation with PCV. Statistical analysis was performed on the obtained values and the components of mechanical ventilation in relation to the outcome of the patients. Results The mechanical power calculated daily in burn patients was 22.83 ± SD joule per minute (J/min). Higher values of mechanical power were significantly related to the mortality (P 0.029) regardless of ventilation time, as well as higher values of PEEP, peak pressure, plateau pressure and driving pressure ( P <0.001), respiratory rate (P 0.01), variation of inspiratory pressure (P 0.03) and lower values of tidal volume (P 0.005). Conclusion In this analysis of mechanical ventilation, mean values of mechanical power in burn patients were elevated and that, regardless of mechanical ventilation time, these values are related to mortality, as well as higher values of pressures, driving pressure, respiratory rate and lower values of tidal volume, indicating the importance of stress frequency and propulsion force to overcome lung elastance.","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47550146","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
K. Benavente, E. Robbins, Bradley Fujiuchi, K. Manzoor
Introduction Non-invasive ventilation (NIV) has a significant role in supporting patients with respiratory failure with the goal of avoiding mechanical ventilation. Traditionally, NIV has been applied using dedicated NIV-specific devices but over the last decade, newer generation critical care ventilators have updated their capabilities to include NIV options with improved synchrony and leak compensation. No recent trials have compared the efficacy of new generation critical care ventilators to NIV ventilators. The purpose of this study was to evaluate clinicians attitudes and perceptions toward the use of NIV between the dedicated NIV and critical care ventilators. Methods An online survey of clinicians with seven questions regarding their thoughts and experience in using NIV in acute care settings was posted online and promoted through emails and social media. The survey was anonymous and an exemption of consent was obtained from the Institutional Review Board. Analysis of variants (ANOVA) was done for the total responses in each question, followed by multivariate analysis of variants (MANOVA) for responses per occupation. Results 514 responses from 54 countries were recorded. 151 from North America, 109 from South America, 125 from Europe, 97 from Asia, 21 from Africa, and 11 from Australia. 218 responders were physicians, 218 were respiratory therapists, 28 were nurses, and 50 were reported as other professionals (engineers, biomedical technicians). 346 (67.3%) reported using both types of ventilators for NIV, 91 (17.7%) use only NIV -specific devices, and 77 (15%) only use critical care ventilators (P 0.097), responses per occupation (P < 0.001). 290 (56.4%) have automatic synchronization software on either of their ventilators, 113 (22%) do not, while 111 (21.6%) are unsure if they do (P 0.22), with significant variation by occupation (P 0.008). Regarding synchrony, 233 (45.3%) said NIV ventilators are better, and 165 (32.1%) said critical care ventilators are better, while 116 (22.5%) said both are similar (P 0.59) with significant variation by occupation (P 0.04). Regarding leak compensation, 241 (46.9%) said NIV ventilators are better, and 146 (284%) said critical care ventilators are better, while 127 (24.7%) said both are similar (P 0.6) without significant variation by occupation (P 0.07). Regarding the general opinion of superiority, 273 (53.1%) said NIV ventilators are better, 131 (25.5%) said critical care ventilators are better, and 110 (21.4%) said both are similar (P 0.42) without significant variation by occupation (P 0.098). Conclusion Despite the lack of evidence, there is wide variability in opinion with no clear consensus regarding the clinicians’ attitude towards which ventilators are superior to use during NIV, especially according to surveyed occupation.
{"title":"Exploring clinicians' beliefs and practices regarding Non-Invasive Ventilation devices: An international survey study","authors":"K. Benavente, E. Robbins, Bradley Fujiuchi, K. Manzoor","doi":"10.53097/jmv.10078","DOIUrl":"https://doi.org/10.53097/jmv.10078","url":null,"abstract":"Introduction Non-invasive ventilation (NIV) has a significant role in supporting patients with respiratory failure with the goal of avoiding mechanical ventilation. Traditionally, NIV has been applied using dedicated NIV-specific devices but over the last decade, newer generation critical care ventilators have updated their capabilities to include NIV options with improved synchrony and leak compensation. No recent trials have compared the efficacy of new generation critical care ventilators to NIV ventilators. The purpose of this study was to evaluate clinicians attitudes and perceptions toward the use of NIV between the dedicated NIV and critical care ventilators. Methods An online survey of clinicians with seven questions regarding their thoughts and experience in using NIV in acute care settings was posted online and promoted through emails and social media. The survey was anonymous and an exemption of consent was obtained from the Institutional Review Board. Analysis of variants (ANOVA) was done for the total responses in each question, followed by multivariate analysis of variants (MANOVA) for responses per occupation. Results 514 responses from 54 countries were recorded. 151 from North America, 109 from South America, 125 from Europe, 97 from Asia, 21 from Africa, and 11 from Australia. 218 responders were physicians, 218 were respiratory therapists, 28 were nurses, and 50 were reported as other professionals (engineers, biomedical technicians). 346 (67.3%) reported using both types of ventilators for NIV, 91 (17.7%) use only NIV -specific devices, and 77 (15%) only use critical care ventilators (P 0.097), responses per occupation (P < 0.001). 290 (56.4%) have automatic synchronization software on either of their ventilators, 113 (22%) do not, while 111 (21.6%) are unsure if they do (P 0.22), with significant variation by occupation (P 0.008). Regarding synchrony, 233 (45.3%) said NIV ventilators are better, and 165 (32.1%) said critical care ventilators are better, while 116 (22.5%) said both are similar (P 0.59) with significant variation by occupation (P 0.04). Regarding leak compensation, 241 (46.9%) said NIV ventilators are better, and 146 (284%) said critical care ventilators are better, while 127 (24.7%) said both are similar (P 0.6) without significant variation by occupation (P 0.07). Regarding the general opinion of superiority, 273 (53.1%) said NIV ventilators are better, 131 (25.5%) said critical care ventilators are better, and 110 (21.4%) said both are similar (P 0.42) without significant variation by occupation (P 0.098). Conclusion Despite the lack of evidence, there is wide variability in opinion with no clear consensus regarding the clinicians’ attitude towards which ventilators are superior to use during NIV, especially according to surveyed occupation.","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46216209","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Introduction High Flow Oxygen Therapy via Nasal Cannula (HFNC) has documented advantages over conventional oxygen therapy (COT). It’s been noted to improve the survival rate among patients with acute hypoxemic respiratory failure, and potentially reduce the incidence of more invasive care. Adjustable oxygen concentration and higher flows that match the inspiratory demand of the patient with respiratory distress result in less entrainment of room air, which dilutes the fraction of inspired oxygen (FiO2) and therefore reduces effectiveness of intended use. Higher flows have been demanded by the clinical community and are associated with a reduction of both PaCO2 and metabolic work. Newer High Flow devices offer higher flow rates up to 80 liters per minute. We examined whether the use of 60 and 80 liters per minute set flows would create an increased risk of gastric insufflation and possibly aspiration. Methods Bench study to compare the pressures generated using different flow rates in two commercially available HFNC devices in three different conditions: Open and closed system (mouth) breathing, breathing against active exhalation, and complete downstream occlusion. Results Our bench study found that high flow rate therapy did not elevate airway pressures to a level that would result in gastric distention and potential aspiration. In the open mouth test, the pressure ranged from minimum 0.2 to maximum of 1.3 cmH2O, and from minimum of 0.52 to 5.27 cmH2O in the closed mouth test. In the active breathing test, the pressures ranged from minimum 1.5 to 6 cmH2O. In the complete occlusion test, the pressures ranged from minimum 0.37 to 4.49 cmH2O. Conclusion Flows provided during HFNC therapy do not pose a hazard of creating high pressures which exceed esophageal opening pressure and pose a risk of gastric distention. The higher flow rates may reduce the risk associated with the potential false positive prediction of HFNC failure when therapy is not set to match the patient’s inspiratory peak flow demand. The benefit of higher flows to match the inspiratory demand provides a rarely recognized additional benefit of improving the accuracy of predictive indices such as the ROX index and allows for high flow therapy to more fully achieve its intended use.
{"title":"High Flow Oxygen Therapy – Risks and Rewards","authors":"Stephen Tunnell","doi":"10.53097/jmv.10077","DOIUrl":"https://doi.org/10.53097/jmv.10077","url":null,"abstract":"Introduction High Flow Oxygen Therapy via Nasal Cannula (HFNC) has documented advantages over conventional oxygen therapy (COT). It’s been noted to improve the survival rate among patients with acute hypoxemic respiratory failure, and potentially reduce the incidence of more invasive care. Adjustable oxygen concentration and higher flows that match the inspiratory demand of the patient with respiratory distress result in less entrainment of room air, which dilutes the fraction of inspired oxygen (FiO2) and therefore reduces effectiveness of intended use. Higher flows have been demanded by the clinical community and are associated with a reduction of both PaCO2 and metabolic work. Newer High Flow devices offer higher flow rates up to 80 liters per minute. We examined whether the use of 60 and 80 liters per minute set flows would create an increased risk of gastric insufflation and possibly aspiration. Methods Bench study to compare the pressures generated using different flow rates in two commercially available HFNC devices in three different conditions: Open and closed system (mouth) breathing, breathing against active exhalation, and complete downstream occlusion. Results Our bench study found that high flow rate therapy did not elevate airway pressures to a level that would result in gastric distention and potential aspiration. In the open mouth test, the pressure ranged from minimum 0.2 to maximum of 1.3 cmH2O, and from minimum of 0.52 to 5.27 cmH2O in the closed mouth test. In the active breathing test, the pressures ranged from minimum 1.5 to 6 cmH2O. In the complete occlusion test, the pressures ranged from minimum 0.37 to 4.49 cmH2O. Conclusion Flows provided during HFNC therapy do not pose a hazard of creating high pressures which exceed esophageal opening pressure and pose a risk of gastric distention. The higher flow rates may reduce the risk associated with the potential false positive prediction of HFNC failure when therapy is not set to match the patient’s inspiratory peak flow demand. The benefit of higher flows to match the inspiratory demand provides a rarely recognized additional benefit of improving the accuracy of predictive indices such as the ROX index and allows for high flow therapy to more fully achieve its intended use.","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45735766","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Burns are skin lesions determined by the thermal energy of heat transfer with cellular protein denaturation. Although infrequent during pregnancy, they can be fatal for both the mother and fetus. The outcome depends on factors related to the burns themselves, such as depth and percentage of body surface burned. Burns that affect more than 20% of the body surface can cause systemic inflammatory response syndrome (SIRS) and acute respiratory distress syndrome (ARDS) with high rates of fetal death and asphyxia. In ARDS, the prone position has been used for over 40 years to promote homogenization of stress distribution and pulmonary strain with improved ventilation/perfusion. However, pregnancy and major burns may constitute relative contraindications related to the prone position due to abdominal and pelvic compression, difficulty in monitoring fetal heartbeats and complications in face and belly burns. The set of contraindications associated with the need for the prone position guided the objective of this case report, which aimed to describe and review the literature to discuss the clinical case, as well as demonstrate the favorable results of gas exchange and ventilatory mechanics in relation to the prone position in pregnant woman with major burns without complications.
{"title":"Prone position in pregnant woman with major burns with severe ARDS on mechanical ventilation","authors":"C. Franck","doi":"10.53097/jmv.10079","DOIUrl":"https://doi.org/10.53097/jmv.10079","url":null,"abstract":"Burns are skin lesions determined by the thermal energy of heat transfer with cellular protein denaturation. Although infrequent during pregnancy, they can be fatal for both the mother and fetus. The outcome depends on factors related to the burns themselves, such as depth and percentage of body surface burned. Burns that affect more than 20% of the body surface can cause systemic inflammatory response syndrome (SIRS) and acute respiratory distress syndrome (ARDS) with high rates of fetal death and asphyxia. In ARDS, the prone position has been used for over 40 years to promote homogenization of stress distribution and pulmonary strain with improved ventilation/perfusion. However, pregnancy and major burns may constitute relative contraindications related to the prone position due to abdominal and pelvic compression, difficulty in monitoring fetal heartbeats and complications in face and belly burns. The set of contraindications associated with the need for the prone position guided the objective of this case report, which aimed to describe and review the literature to discuss the clinical case, as well as demonstrate the favorable results of gas exchange and ventilatory mechanics in relation to the prone position in pregnant woman with major burns without complications.","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48937234","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Patient-ventilator asynchronies can occur at any phase throughout the respiratory cycle. Because it has been associated with patient outcomes, it is important to recognize and address these asynchronies. Bedside interpretation of air flow and airway pressure waveforms are helpful for recognizing patient–ventilator asynchronies and optimizing ventilator settings. Patient effort is sensed by either a drop in circuit pressure (pressure trigger) or circuit bias flow (flow trigger). Triggering delay is the time interval between the start of the neural and mechanical inspiration. Triggers must be sensitive enough to recognize patient effort to avoid imposing an additional load but not too sensitive to avoid auto-triggering. Despite improvements in triggering technology, triggering asynchronies continue to occur and are manifest, among others, by delayed triggering. Keywords: asynchrony, patient effort, trigger, delayed triggering
{"title":"Identifying asynchronies: Delayed triggering","authors":"Victor Perez, Jamille Pasco","doi":"10.53097/jmv.10080","DOIUrl":"https://doi.org/10.53097/jmv.10080","url":null,"abstract":"Patient-ventilator asynchronies can occur at any phase throughout the respiratory cycle. Because it has been associated with patient outcomes, it is important to recognize and address these asynchronies. Bedside interpretation of air flow and airway pressure waveforms are helpful for recognizing patient–ventilator asynchronies and optimizing ventilator settings. Patient effort is sensed by either a drop in circuit pressure (pressure trigger) or circuit bias flow (flow trigger). Triggering delay is the time interval between the start of the neural and mechanical inspiration. Triggers must be sensitive enough to recognize patient effort to avoid imposing an additional load but not too sensitive to avoid auto-triggering. Despite improvements in triggering technology, triggering asynchronies continue to occur and are manifest, among others, by delayed triggering. Keywords: asynchrony, patient effort, trigger, delayed triggering","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41495146","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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