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Airway pressure morphology and respiratory muscle activity during end-inspiratory occlusions in pressure support ventilation

BACKGROUND: The driving pressure of the respiratory system is a valuable indicator of global lung stress during passive mechanical ventilation. Monitoring lung stress in assisted ventilation is indispensable, but achieving passive conditions in spontaneously breathing patients to measure driving pre...

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Autores principales: Soundoulounaki, Stella, Akoumianaki, Evangelia, Kondili, Eumorfia, Pediaditis, Emmanouil, Prinianakis, Georgios, Vaporidi, Katerina, Georgopoulos, Dimitris
Formato: Online Artículo Texto
Lenguaje:English
Publicado: BioMed Central 2020
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Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7385937/
https://www.ncbi.nlm.nih.gov/pubmed/32723356
http://dx.doi.org/10.1186/s13054-020-03169-x
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author Soundoulounaki, Stella
Akoumianaki, Evangelia
Kondili, Eumorfia
Pediaditis, Emmanouil
Prinianakis, Georgios
Vaporidi, Katerina
Georgopoulos, Dimitris
author_facet Soundoulounaki, Stella
Akoumianaki, Evangelia
Kondili, Eumorfia
Pediaditis, Emmanouil
Prinianakis, Georgios
Vaporidi, Katerina
Georgopoulos, Dimitris
author_sort Soundoulounaki, Stella
collection PubMed
description BACKGROUND: The driving pressure of the respiratory system is a valuable indicator of global lung stress during passive mechanical ventilation. Monitoring lung stress in assisted ventilation is indispensable, but achieving passive conditions in spontaneously breathing patients to measure driving pressure is challenging. The accuracy of the morphology of airway pressure (Paw) during end-inspiratory occlusion to assure passive conditions during pressure support ventilation has not been examined. METHODS: Retrospective analysis of end-inspiratory occlusions obtained from critically ill patients during pressure support ventilation. Flow, airway, esophageal, gastric, and transdiaphragmatic pressures were analyzed. The rise of gastric pressure during occlusion with a constant/decreasing transdiaphragmatic pressure was used to identify and quantify the expiratory muscle activity. The Paw during occlusion was classified in three patterns, based on the differences at three pre-defined points after occlusion (0.3, 1, and 2 s): a “passive-like” decrease followed by plateau, a pattern with “clear plateau,” and an “irregular rise” pattern, which included all cases of late or continuous increase, with or without plateau. RESULTS: Data from 40 patients and 227 occlusions were analyzed. Expiratory muscle activity during occlusion was identified in 79% of occlusions, and at all levels of assist. After classifying occlusions according to Paw pattern, expiratory muscle activity was identified in 52%, 67%, and 100% of cases of Paw of passive-like, clear plateau, or irregular rise pattern, respectively. The driving pressure was evaluated in the 133 occlusions having a passive-like or clear plateau pattern in Paw. An increase in gastric pressure was present in 46%, 62%, and 64% of cases at 0.3, 1, and 2 s, respectively, and it was greater than 2 cmH(2)O, in 10%, 20%, and 15% of cases at 0.3, 1, and 2 s, respectively. CONCLUSIONS: The pattern of Paw during an end-inspiratory occlusion in pressure support cannot assure the absence of expiratory muscle activity and accurate measurement of driving pressure. Yet, because driving pressure can only be overestimated due to expiratory muscle contraction, in everyday practice, a low driving pressure indicates an absence of global lung over-stretch. A measurement of high driving pressure should prompt further diagnostic workup, such as a measurement of esophageal pressure.
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spelling pubmed-73859372020-07-28 Airway pressure morphology and respiratory muscle activity during end-inspiratory occlusions in pressure support ventilation Soundoulounaki, Stella Akoumianaki, Evangelia Kondili, Eumorfia Pediaditis, Emmanouil Prinianakis, Georgios Vaporidi, Katerina Georgopoulos, Dimitris Crit Care Research BACKGROUND: The driving pressure of the respiratory system is a valuable indicator of global lung stress during passive mechanical ventilation. Monitoring lung stress in assisted ventilation is indispensable, but achieving passive conditions in spontaneously breathing patients to measure driving pressure is challenging. The accuracy of the morphology of airway pressure (Paw) during end-inspiratory occlusion to assure passive conditions during pressure support ventilation has not been examined. METHODS: Retrospective analysis of end-inspiratory occlusions obtained from critically ill patients during pressure support ventilation. Flow, airway, esophageal, gastric, and transdiaphragmatic pressures were analyzed. The rise of gastric pressure during occlusion with a constant/decreasing transdiaphragmatic pressure was used to identify and quantify the expiratory muscle activity. The Paw during occlusion was classified in three patterns, based on the differences at three pre-defined points after occlusion (0.3, 1, and 2 s): a “passive-like” decrease followed by plateau, a pattern with “clear plateau,” and an “irregular rise” pattern, which included all cases of late or continuous increase, with or without plateau. RESULTS: Data from 40 patients and 227 occlusions were analyzed. Expiratory muscle activity during occlusion was identified in 79% of occlusions, and at all levels of assist. After classifying occlusions according to Paw pattern, expiratory muscle activity was identified in 52%, 67%, and 100% of cases of Paw of passive-like, clear plateau, or irregular rise pattern, respectively. The driving pressure was evaluated in the 133 occlusions having a passive-like or clear plateau pattern in Paw. An increase in gastric pressure was present in 46%, 62%, and 64% of cases at 0.3, 1, and 2 s, respectively, and it was greater than 2 cmH(2)O, in 10%, 20%, and 15% of cases at 0.3, 1, and 2 s, respectively. CONCLUSIONS: The pattern of Paw during an end-inspiratory occlusion in pressure support cannot assure the absence of expiratory muscle activity and accurate measurement of driving pressure. Yet, because driving pressure can only be overestimated due to expiratory muscle contraction, in everyday practice, a low driving pressure indicates an absence of global lung over-stretch. A measurement of high driving pressure should prompt further diagnostic workup, such as a measurement of esophageal pressure. BioMed Central 2020-07-28 /pmc/articles/PMC7385937/ /pubmed/32723356 http://dx.doi.org/10.1186/s13054-020-03169-x Text en © The Author(s) 2020 Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
spellingShingle Research
Soundoulounaki, Stella
Akoumianaki, Evangelia
Kondili, Eumorfia
Pediaditis, Emmanouil
Prinianakis, Georgios
Vaporidi, Katerina
Georgopoulos, Dimitris
Airway pressure morphology and respiratory muscle activity during end-inspiratory occlusions in pressure support ventilation
title Airway pressure morphology and respiratory muscle activity during end-inspiratory occlusions in pressure support ventilation
title_full Airway pressure morphology and respiratory muscle activity during end-inspiratory occlusions in pressure support ventilation
title_fullStr Airway pressure morphology and respiratory muscle activity during end-inspiratory occlusions in pressure support ventilation
title_full_unstemmed Airway pressure morphology and respiratory muscle activity during end-inspiratory occlusions in pressure support ventilation
title_short Airway pressure morphology and respiratory muscle activity during end-inspiratory occlusions in pressure support ventilation
title_sort airway pressure morphology and respiratory muscle activity during end-inspiratory occlusions in pressure support ventilation
topic Research
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7385937/
https://www.ncbi.nlm.nih.gov/pubmed/32723356
http://dx.doi.org/10.1186/s13054-020-03169-x
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