Full Text View
Pressure support ventilation in intensive care patients receiving prolonged invasive ventilation
Wisam Al-Bassam, Tapan Parikh, Ary Serpa Neto, Yamamah Idrees, Mark A Kubicki, Carol L Hodgson, Ashwin Subramaniam, Mallikarjuna Ponnapa Reddy, Navya Gullapalli, Claire Michel, Madeline Coxwell Matthewman, Jack Naughton, Jason Pereira, Yahya Shehabi, Rinaldo Bellomo
Crit Care Resusc 2021; 23 (4): 394-402
- Wisam Al-Bassam 1
- Tapan Parikh 1
- Ary Serpa Neto 2, 3, 4
- Yamamah Idrees 5
- Mark A Kubicki 5
- Carol L Hodgson 6
- Ashwin Subramaniam 7
- Mallikarjuna Ponnapa Reddy 7
- Navya Gullapalli 8
- Claire Michel 9
- Madeline Coxwell Matthewman 9
- Jack Naughton 9
- Jason Pereira 6
- Yahya Shehabi 1, 10
- Rinaldo Bellomo 2, 4, 9, 11
BACKGROUND: To our knowledge, the use and management of pressure support ventilation (PSV) in patients receiving prolonged (≥ 7 days) invasive mechanical ventilation has not previously been described.
OBJECTIVE: To collect and analyse data on the use and management of PSV in critically ill patients receiving prolonged ventilation.
DESIGN, SETTING AND PARTICIPANTS: We performed a multicentre retrospective observational study in Australia, with a focus on PSV in patients ventilated for ≥ 7 days.
MAIN OUTCOME MEASURES: We obtained detailed data on ventilator management twice daily (8am and 8pm moments) for the first 7 days of ventilation.
RESULTS: Among 143 consecutive patients, 90/142 (63.4%) had received PSV by Day 7, and PSV accounted for 40.5% (784/1935) of ventilation moments. The most common pressure support level was 10 cmH
2O (352/780) observations [45.1%]) with little variation over time, and 37 of 114 patients (32.4%) had no change in pressure support. Mean tidal volume during PSV was 8.3 (7.0–9.5) mL/kg predicted bodyweight (PBW) compared with 7.5 (7.0–8.3) mL/kg PBW during mandatory ventilation (P < 0.001). For 74.6% (247/331) of moments, despite a tidal volume of more than 8 mL/kg PBW, the pressure support level was not changed. Among 122 patients exposed to PSV, 97 (79.5%) received likely over-assistance according to rapid shallow breathing index criteria. Of 784 PSV moments, 411 (52.4%) were also likely over-assisted according to rapid shallow breathing index criteria, and 269/346 (77.7%) having no subsequent adjustment of pressure support.
CONCLUSIONS: In patients receiving prolonged ventilation, almost two-thirds received PSV, which accounted for 40.5% of mechanical ventilation time. Half of the PSV-treated patients were exposed to high tidal volume and two-thirds to likely over-assistance. These observations provide evidence that can be used to inform interventional studies of PSV management.
- Slutsky AS. Mechanical ventilation. American College of Chest Physicians’ Consensus Conference. Chest 1993; 104: 1833-59.
- Acute Respiratory Distress Syndrome Network; Brower RG, Matthay MA, Morris A, et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000; 342: 1301-8.
- Amato MB, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med 2015; 372: 747-55.
- Sassoon CS, Zhu E, Caiozzo VJ. Assist-control mechanical ventilation attenuates ventilator-induced diaphragmatic dysfunction. Am J Respir Crit Care Med 2004; 170: 626-32.
- Levine S, Nguyen T, Taylor N, et al. Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. N Engl J Med 2008; 358: 1327-35.
- Brochard L. Less sedation in intensive care: the pendulum swings back. Lancet 2010; 375: 436-8.
- Boles JM, Bion J, Connors A, et al. Weaning from mechanical ventilation. Eur Respir J 2007; 29: 1033-56.
- MacIntyre NR. Respiratory function during pressure support ventilation. Chest 1986; 89: 677-83.
- Brochard L, Rauss A, Benito S, et al. Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation. Am J Respir Crit Care Med 1994; 150: 896-903.
- Esteban A, Frutos F, Tobin MJ, et al. A comparison of four methods of weaning patients from mechanical ventilation. Spanish Lung Failure Collaborative Group. N Engl J Med 1995; 332: 345-50.
- Pinto Da Costa N, Di Marco F, Lyazidi A, et al. Effect of pressure support on end-expiratory lung volume and lung diffusion for carbon monoxide. Crit Care Med 2011; 39: 2283-9.
- Thille AW, Cabello B, Galia F, et al. Reduction of patient-ventilator asynchrony by reducing tidal volume during pressure-support ventilation. Intensive Care Med 2008; 34: 1477-86.
- Brochard L, Harf A, Lorino H, Lemaire F. Inspiratory pressure support prevents diaphragmatic fatigue during weaning from mechanical ventilation. Am Rev Respir Dis 1989; 139: 513-21.
- Pletsch-Assuncao R, Caleffi Pereira M, Ferreira JG, et al. Accuracy of invasive and noninvasive parameters for diagnosing ventilatory overassistance during pressure support ventilation. Crit Care Med 2018; 46: 411-7.
- Rose L, Presneill JJ, Johnston L, et al. Ventilation and weaning practices in Australia and New Zealand. Anaesth Intensive Care 2009; 37: 99-107.
- Jabaley CS, Groff RF, Sharifpour M, et al. Modes of mechanical ventilation vary between hospitals and intensive care units within a university healthcare system: a retrospective observational study. BMC Res Notes 2018; 11: 425.
- Esteban A, Anzueto A, Alia I, et al. How is mechanical ventilation employed in the intensive care unit? An international utilization review. Am J Respir Crit Care Med 2000; 161: 1450-8.
- Simonis F, Binnekade J, Barber A, et al. Effect of a low vs intermediate Tidal Volume Strategy on Ventilator-Free Days in Intensive Care unit Patients Without ARDS. A Randomised Clinical Trial. JAMA 2018; 320 (18): 1872-1880.
- Clark FJ, von Euler C. On the regulation of depth and rate of breathing. J Physiol 1972; 222: 267-95.
- Jubran A, Van de Graaff WB, Tobin MJ. Variability of patient-ventilator interaction with pressure support ventilation in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1995; 152: 129-36.
- Leung P, Jubran A, Tobin MJ. Comparison of assisted ventilator modes on triggering, patient effort, and dyspnea. Am J Respir Crit Care Med 1997; 155: 1940-8.
- Petrof BJ, Hussain SN. Ventilator-induced diaphragmatic dysfunction: what have we learned? Curr Opin Crit Care 2016; 22: 67-72.
- Al-Bassam W, Dade F, Bailey M, et al. “Likely overassistance” during invasive pressure support ventilation in patients in the intensive care unit: a multicentre prospective observational study. Crit Care Resusc 2019; 21: 18-24.