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Patient - Ventilator Asynchrony in Non - invasive Ventilation and Solution

Patient - Ventilator Asynchrony in Non - invasive Ventilation and Solution. Prof. Dr. Kürşat Uzun Selçuk University , Meram Medical Faculty , Pulmonary Diseases and Critical Care Department Konya. Non - invasive ventilation. NIV. Decrease work of breathing Improve gas exchange

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Patient - Ventilator Asynchrony in Non - invasive Ventilation and Solution

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  1. Patient-VentilatorAsynchrony in Non-invasiveVentilationandSolution Prof. Dr. Kürşat Uzun Selçuk University, Meram MedicalFaculty, PulmonaryDiseasesandCritical Care Department Konya

  2. Non-invasiveventilation

  3. NIV • Decreasework of breathing • Improvegasexchange • Relievedyspnea • Reducingtheintubation rate • AECOPD from 63% to 21% • Shorten ICU stay • Decreasenosocomialinfection • Decreasemortality • AECOPD from 25% to 9% EurRespir J 2008; 31: 874–886

  4. NIV Failure/Success • 40 % • Clinicalstatus • theselection of appropriatepatients • Acuity of illness • the first 1–2 h of NPPV • Trainedteam • Interface • poor mask tolerance, • skin lesions • leaks • Acceptance • Compliance • Synchrony

  5. NIV

  6. Problem Presence of leaksaroundthe mask Ventilatorsettings Interfaces Agitation Patient-ventilatorasynchrony Discomfort Worseningtheclinicalsituation

  7. Patient-ventilatorasynchrony

  8. NIV • Pressuresupport is themostfrequentlyusedventilatorymodeduring NIV (80%) • Triggering of ventilator • Pressurizationslopeandinspiratoryflow • Pressuresupportlevel • Cycling • Patientcontrol • respiratory rate • duration of inspiration

  9. Patient-ventilatorasynchrony • Transdiaphragmaticpressure (Pdi) • Diaphragmaticelectromyography • Esophagealpressure • Flow-pressurewaveform • Wastedeffort • Doubletriggering • Auto-cycledbreaths • Clinical • Tachypnea • Activation of inspiratoryneckmuscles • Ineffectivetriggeringefforts • Forcedexpiration

  10. Patient-ventilatorasynchronyLeaks Phase 3 Delayedcycling (prolongedinspiration) Phase 2 Decreased rate of inspiratorypressurerise Phase 1 Delayedtriggering Ineffectiveeffort Auto-triggering Phase 4 PEEP Loss Pressure PEEP Inspiration Expiration Time Resp Care 2009;54(1): 85-96 Am J Respir Crit Care Med 2001;163:1059-63

  11. Cycling • Inspiratoryflowdecreasesto a predeterminedfraction of peakinspiratoryflow (Expiratorytrigger) • Increased WOB • COPD • Usually 25% of V’peak Cycling Inspiration expiration

  12. Delayedcycling • The presence of leaks • prolongedmechanicalinspiration • İnspiratoryflowdoes not reachthecycling-offcriterion • Delayedcycling-off Calderini et al. Intensive Care Med 1999; 25: 662–7

  13. Delayedcycling COPD CriticalCare 2006, 10:236

  14. ProlongedinspirationSolve • Reducing • theleaks • Mask position • Ventilatorinsufflation time • Limiting total inspiratorypressure • Pressuresupportlevel • PEEP level • Increasingtheexpiratorytrigger • 50 % ormore • Reducingthemaximalinspiratory time • 0.8-1.2 second Intensive Care Med 2004; 30:S65 Clin Pulm Med 2007; 14:350-9 Intensive Care Med 1999; 25: 662-7 Nava S et al. Breathe 2009;5 (4)

  15. DelayedcyclingSolve Highervalue of ET decreasesdelayedcycling Am J RespirCrit Care Med Vol 172. pp 1283–1289, 2005 CriticalCare 2006, 10:236

  16. Excessivetightness • Patientdiscomfort • NIMV intolerance • Highpressurisation rate increasesairleakagedespitesufficient mask fitting

  17. Autotriggering • Expiratoryleaks can generate a presuredropbelowtheexternal PEEP level • Simulatingthepatient’seffort • Triggering a ventilatorbreath • Shortcycle • Flowdistortion • Patientdoes not generateeffort • Fighttheventilator Nava S et al. Breathe 2009;5 (4)

  18. Auto-triggeringSolve • Decreasing triggering sensitivity • Carefuladjustment of setting • Avoidineffectivetriggering

  19. Ineffectiveinspiratorytriggering • Theinspiratorymusclecontractiondoes not triggertheventilator • Highlevel of support • Whendynamichyperinflation (COPD) • PEEPi • Filter Nava S et al. Breathe 2009;5 (4) L.achour, ComputBiol Med. 2007 Sep;37(9):1308-20

  20. Ineffectivetriggering • Dynamichyperinflation • Inspiratorythresholdload • PEEPi has beenshowntoleadineffectiveefforts in COPD • Leakswereshownto • increasethetriggerdelayand • thenumber of ineffectivebreaths • Pressuresupportlevel

  21. PS IE

  22. Respiratory rate andineffectivetriggering

  23. Ineffectiveeffortindex • 48/h, night • Highlevels of IPAP • VT • PEEPi • High RR • Therewas no differenceaccordingtocompliancelevel n: 48 patients COPD, OHS, KS Theydid not foundanyassociationsbetween a spesificventilator

  24. Double-triggering • Insufficientlevel of pressuresupport • Increasedinspiratorydemand • Ventilator’spressurization time is tooshort

  25. Patient–ventilatorasynchronyduringnon-invasiveventilationforacuterespiratoryfailure: a multicenterstudyVignaux et al. Intensive Care Med 2009; 35:840--6 3 hospital , n:60 ICU ventilator NIV EMGdi Pressure Flow COPD 40%, Heartfailure 28%, OHS 15%

  26. Diaphragmatic EMG (EMGdi)

  27. Asynchrony 23%, Severe asynchrony 43%

  28. ICU ventilatorwasused Intubation rate Lenght of stay in ICU Mortality, no difference Level of pressuresupport Themagnitude of leaks

  29. Interfaces

  30. Mask andasynchrony

  31. improves gas exchange • Ineffectiveinspiratoryefforts • less efficient than the mask in reducing inspiratorymuscle effort and • worsens patient–ventilator synchrony

  32. Ventilatorsettings

  33. Triggering • Pressure • Flow • Flowtriggering • Reduce • İnspiratoryeffort • Triggeringdelay (COPD) Mostsensible Lesssensible Suitable Nava S et al. Thorax 1997;52:249-254

  34. Pressuresupportlevel • Insufficientsupportleadingtoincreasedrespiratorymuscleload • Excessivesupport • Dynamichyperinflation • PEEPi • Increase in leaksanddecrease in delivered VT Pressuresupport can be titrated on the VTE (8-10 ml/kg) and thepatient’srespiratory rate, whichshouldremainbelow <30/min

  35. PressurizationandinspiratoryflowRise time • Increasingcomfort • Theincrementalincrease in Pawper time unit • COPD • Shortrise time 0.05-0.1 • Steepslope is associatedwithless WOB • Neuromuscular • Slowrise time 0.3-0.4

  36. Mode

  37. Am J Respir Crit Care Med Vol 164. pp 1606–1611, 2001

  38. NAVANeurallyadjustedventilatorassisted • Diaphragmelectricalactivity (EAdi) • Esophagealelectrode (naso-gastriccatheter) • Assistance • Onset • End • Level • Synchronybetweenneuralandmechanicaltimingshould be guaranteed at anyphase of respiration • Diaphragmunloading • Reduction in thepatient’seffort • Ineffectiveeffort • Experimentalmode Sinderby C, et al. Nat Med 1999;5:1433-6

  39. Machine

  40. Triggerdelay (Td) Inspiratorytrigger

  41. Inspiratory:expiratorycycling ΔTi is thedifference (tidiff) between the patient (tipat) and ventilator (tiassist)inspiratorydurations

  42. FlowShapeSignal Digital Auto-Trak

  43. Conclusion • Appropriate • patient • Interfaces • Ventilator settings • Monitorisation

  44. Thankyou

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