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Nektaria Xirouchaki
Eumorfia Kondili
Proportional assist ventilation
Katerina Vaporidi with load-adjustable gain factors in critically ill
George Xirouchakis
Maria Klimathianaki patients: comparison with pressure support
George Gavriilidis
Evi Alexandopoulou
Maria Plataki
Christina Alexopoulou
Dimitris Georgopoulos
Received: 8 April 2008 Abstract Objectives: It is not significantly lower in PAV+ than that
Accepted: 16 June 2008 known if proportional assist ventila- in PS (11.1 vs. 22.0%, P = 0.040, OR
tion with load-adjustable gain factors 0.443, 95% CI 0.206–0.952). The
Ó Springer-Verlag 2008 (PAV+) may be used as a mode of proportion of patients exhibiting
Supported by the Society of Critical Care of support in critically ill patients. The major patient–ventilator dyssynchr-
Crete. aim of this study was to examine the onies at least during one occasion and
effectiveness of sustained use of after adjusting the initial ventilator
Electronic supplementary material settings, was significantly lower in
The online version of this article PAV+ in critically ill patients and
(doi:10.1007/s00134-008-1209-2) contains compare it with pressure support PAV+ than in PS (5.6 vs. 29.0%, P\
supplementary material, which is available ventilation (PS). Design and set- 0.001, OR 0.1, 95% CI 0.06–0.4). The
to authorized users. ting: Randomized study in the proportion of patients meeting criteria
intensive care unit of a university for unassisted breathing did not differ
hospital. Methods: A total of 208 between modes. Conclusions:
critically ill patients mechanically PAV+ may be used as a useful mode of
ventilated on controlled modes for at support in critically ill patients.
least 36 h and meeting certain criteria Compared to PS, PAV+ increases the
N. Xirouchaki E. Kondili K. Vaporidi were randomized to receive either PS probability of remaining on
G. Xirouchakis M. Klimathianaki (n = 100) or PAV+ (n = 108). Spe- spontaneous breathing, while it
G. Gavriilidis E. Alexandopoulou cific written algorithms were used to considerably reduces the incidence of
M. Plataki C. Alexopoulou adjust the ventilator settings in each patient–ventilator asynchronies.
D. Georgopoulos ()) mode. PAV+ or PS was continued for
Intensive Care Medicine Department, 48 h unless the patients met pre- Keywords Controlled modes
University Hospital of Heraklion, Assisted modes
Medical School, University of Crete,
defined criteria either for switching to
Heraklion, Crete, Greece controlled modes (failure criteria) or Patient–ventilator interaction
e-mail: georgop@med.uoc.gr for breathing without ventilator
Fax: +30-2810392636 assistance. Results: Failure rate was
Measurements
The proportion of patients exhibiting major patient– PAV+ (see ESM). Thereafter, these variables did not
ventilator dyssynchronies was significantly lower in the differ between modes.
PAV+ group than that in the PS (5.6 vs. 39.0%, P \ Individual examination of Pplat during PAV+
0.001, OR 0.1, 95% CI 0.04–0.251). The difference (PplatPAVþ ) showed that from a total of 744 measurements
remained significant even after excluding measurements only on 9 occasions (1.2%) and in 5 patients (4.6%)
at initial assist level which was chosen rather arbitrary PplatPAVþ was above 30 cmH2O (highest value 35.2
(5.6 vs. 29%, P\0.001, OR 0.144, 95% CI 0.057–0.365). cmH2O). Three out of these five patients failed on PAV+
In the PS group, from a total of 696 measurements, 95 and were switched to controlled mechanical ventilation
(13.6%) revealed a difference between patients’ breathing relatively early. In 94% of the measurements, PplatPAVþ
frequency and ventilator rate (Fig. 3). With PS ineffective was below 26 cmH2O (see ESM).
efforts were the type of major asynchrony observed in all Hemodynamic data did not differ either between
but two measurements. In two patients and on two modes or as a function of time (see ESM).
occasions double triggering was identified. From these
measurements, considerable patient–ventilator dys-
synchronies ([10% of patient’s respiratory efforts) were
observed in 67 (9.6% of the total measurements). In the Discussion
PAV+ group, from a total of 744 measurements, 21
(2.8%) revealed a difference between patients’ breathing The main finding of this study is that PAV+ may be used
frequency and ventilator rate, while considerable dys- as a mode of support in critically ill patients meeting
synchrony was observed in 10 (1.3% of the total). With certain criteria for assisted modes. Compared to PS,
PAV+ only ineffective efforts were observed. during the 48-h period of observation, patients ventilated
The total amount of sedative and vasoactive (nor- with PAV+ exhibited: (1) increased probability of
adrenaline) drugs received within the 48 h of study remaining on assisted or un-assisted spontaneous breath-
period, was slightly but non-significant lower in the ing and (2) better patient–ventilator synchrony.
PAV+ group (see ESM). This difference was entirely due The probability of remaining on spontaneous breath-
to the higher number of patients who failed on PS and ing during the study period was significantly increased in
received increased doses of vasopressors and sedatives patients ventilated with PAV+ when compared with PS.
when they were switched to control modes. The total The failure rate observed in the PS group was remarkably
amount of analgetics was similar between the groups. similar to that reported by Cereda et al. [4] who studied
In PS, immediately upon switching to assisted modes, only patients with ALI/ARDS and used similar inclusion
VT, V0 E, Ppeak and Pmean were significantly higher and criteria to ours. It is not clear why patients ventilated with
Frvent significantly lower than the corresponding values in PAV+ exhibited a lower failure rate than those ventilated
Table 2 Baseline characteristics of the study patients
with PS. The strict pre-defined algorithms for ventilator The end-inspiratory airway pressure, immediately after
and analgo-sedation management, as well as the pre-set rapid airway occlusion during CMV (P1) and the mode of
criteria for failure, indicate that clinical decisions are support, independently predicted the occurrence of failure.
unlikely to play an important role for the observed dif- P1 at constant ventilator settings and PEEPTOT, depends on
ference. Patient–ventilator asynchrony could be a factor, time-constant inequalities and compliance [23]. Since
since considerable asynchrony was observed with PS but ventilator settings, PEEPTOT and respiratory system com-
not with PAV+. A high incidence of asynchrony during pliance did not differ between success and failure patients,
assisted ventilation is associated with a longer duration of the dependency of the main outcome on P1 indicates that
mechanical ventilation [25], while it may affect sleep time-constant inequalities may, to some extent, determine
quality, an important and often unrecognized determinant the outcome. The high incidence of gas exchange deterio-
of outcome of mechanical ventilation [26, 27]. Never- ration in failure patients supports this assumption, since
theless, further studies are needed to resolve if sleep time-constant inequalities is an important determinant of
quality and patient–ventilator asynchrony may underscore gas exchange properties of the lung [28, 29]. Finally, the
the observed difference between modes. stepwise logistic regression analysis suggests that, for a
Table 3 Causes of failurea given P1, patients randomized to PAV+ were at lower risk
for failure than these randomized to PS.
PAV+ PS P The breathing pattern immediately upon switching to
Respiratory distress 8 (7.4) 10 (10.0) 0.507 assisted modes differed significantly between PAV+ and
Extubation failureb 2 (1.9) 2 (2.0) 1.00 PS. With PS, VT was significantly higher and ventilator
Hypoxemia 3 (2.8) 10 (10.0)* 0.043 rate significantly lower than the corresponding values
Hypercapnia 2 (1.9) 3 (3.0) 0.673 with PAV+. The lower ventilator rate was due to the
Hemodynamic instabilityc/arrhythmias 2 (1.9) 6 (6.0) 0.158
Acute ischemic heart event 0 (0.0) 1 (1.0) 0.481 considerable number of ineffective efforts, whereas the
Increased need of sedation 3 (2.8) 3 (3.0) 1.00 higher VT to the inability of the patients to compensate
Inappropriate increase in sedationd 3 (2.8) 1 (1.0) 0.622 for the high assist dialled initially. It follows that with PS,
the breathing pattern was highly dependent on the level
Values are numbers (% of randomized patients)
PAV+ proportional assist ventilation with load adjustable gain of assist and thus, on the caregiver. On the other hand,
factors, PS pressure support with PAV+ the level of assist did not significantly
* Significantly different from PAV+ group influence either the VT or ventilator frequency, the
a
b
Some patients met more than one failure criteria patients being able to maintain the desired breathing
In all patients, re-intubation was performed within the 48-h study pattern over a considerable range of assist. The inability
period. In three patients (2 in PAV+ and 1 in PS) re-intubation was of the patients to compensate the high PS level may cause
performed within 1 h of extubation due to upper airway obstruction.
In the remaining patient (PS group) re-intubation was performed non-synchrony with the ventilator [14], unstable breath-
several hours later for respiratory distress, hypoxemia and hemo- ing [19] and sleep disturbances [26].
dynamic instability Previous studies demonstrated that ineffective efforts
c
Need for norepinephrine [ 0.5 lg/kg per h are common during PS [14, 25]. Our study confirmed this
d
Protocol violation and showed that PAV+ is associated with a signifi-
cant decrease in the incidence of ineffective efforts.
Multiple factors related to patient characteristics, depth
1
of sedation, ventilator settings and operational ventilator
principles, cause this type of asynchrony [30]. In our
on spontaneous breathing
Probability of remaining
0,9
study, patients’ characteristics, sedation management and
standard ventilator settings such as PEEPE and flow
0,8 threshold for triggering did not differ between modes. It
follows that the ventilator operational principles between
0,7 modes is the key factor for the observed difference in the
incidence of patient–ventilator asynchrony [31]. With PS
0,6 Log-rank P=0.041 PS there is a dissociation between inspiratory effort and VT;
PAV+ VT may be adequate or excessive (if assist is high) even
0,5 with very low inspiratory effort [13]. On the other hand,
0 4 8 12 16 20 24 28 32 36 40 44 48
Hours after randomization
with PAV+ the patient retains the ability to maintain VT
Patients at risk
constant over a wide range of assist, while there is a tight
PS 100 92 84 79 78 link between inspiratory effort and VT since the patient’s
PAV+ 108 101 97 97 96 inspiratory effort drives the ventilator [9, 13]. With PS the
observed dependency of VT on the assist level (high VT
Fig. 2 Kaplan–Meier estimates of probability of remaining on
spontaneous breathing (assisted or unassisted) in patients random- with high assist) and the possible uncoupling between
ized to PS and PAV+. PAV+ Proportional assist ventilation with inspiratory effort and VT (relatively high VT with low
load adjustable gain factors, PS pressure support inspiratory effort) [13] may interfere with the triggering
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