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01-05-2006 | Original

Respiratory load compensation during mechanical ventilation—proportional assist ventilation with load-adjustable gain factors versus pressure support

Authors: Eumorfia Kondili, George Prinianakis, Christina Alexopoulou, Eleftheria Vakouti, Maria Klimathianaki, Dimitris Georgopoulos

Published in: Intensive Care Medicine | Issue 5/2006

Abstract

Rationale

In mechanically ventilated patients respiratory system impedance may vary from time to time, resulting, with pressure modalities of ventilator support, in changes in the level of assistance. Recently, implementation of a closed-loop adjustment to continuously adapt the level of assistance to changes in respiratory mechanics has been designed to operate with proportional assist ventilation (PAV+).

Objectives

The aim of this study was to assess, in critically ill patients, the short-term steady-state response of respiratory motor output to added mechanical respiratory load during PAV+ and during pressure support (PS).

Patients and interventions

In 10 patients respiratory workload was increased and the pattern of respiratory load compensation was examined during both modes of support.

Measurements and results

Airway and transdiaphragmatic pressures, volume and flow were measured breath by breath. Without load, both modes provided an equal support as indicated by a similar pressure–time product of the diaphragm per breath, per minute and per litre of ventilation. With load, these values were significantly lower (p < 0.05) with PAV+ than those with PS (5.1 ± 3.7 vs 6.1 ± 3.4 cmH₂O.s, 120.9 ± 77.6 vs 165.6 ± 77.5 cmH₂O.s/min, and 18.7 ± 15.1 vs 24.4 ± 16.4 cmH₂O.s/l, respectively). Contrary to PS, with PAV+ the ratio of tidal volume (V_T) to pressure–time product of the diaphragm per breath (an index of neuroventilatory coupling) remained relatively independent of load. With PAV+ the magnitude of load-induced V_T reduction and breathing frequency increase was significantly smaller than that during PS.

Conclusion

In critically ill patients the short-term respiratory load compensation is more efficient during proportional assist ventilation with adjustable gain factors than during pressure support.

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Esteban A, Anzueto A, Alia I, Gordo F, Apezteguia C, Palizas F, Cide D, Goldwaser R, Soto L, Bugedo G, Rodrigo C, Pimentel J, Raimondi G, Tobin MJ (2000) How is mechanical ventilation employed in the intensive care unit? An international utilization review. Am J Respir Crit Care Med 161:1450–1458PubMed

Brochard L, Harf A, Lorino H, Lemaire F (1989) Inspiratory pressure support prevents diaphragmatic fatigue during weaning from mechanical ventilation. Am Rev Respir Dis 139:513–521PubMed

MacIntyre NR (1986) Respiratory function during pressure support ventilation. Chest 89:677–683PubMedCrossRef

Younes M (1991) Proportional assist ventilation and pressure support ventilation: similarities and differences. In: Marini JJ et al (eds) Ventilatory failure. Springer, Berlin Heidelberg New York, p 361–380

Younes M (1992) Proportional assist ventilation, a new approach to ventilatory support. Theory. Am Rev Respir Dis 145:114–120PubMed

Grasso S, Puntillo F, Mascia L, Ancona G, Fiore T, Bruno F, Slutsky AS, Ranieri VM (2000) Compensation for increase in respiratory workload during mechanical ventilation. Pressure-support versus proportional-assist ventilation. Am J Respir Crit Care Med 161:819–826PubMed

Mitrouska J, Xirouchaki N, Patakas D, Siafakas N, Georgopoulos D (1999) Effects of chemical feedback on respiratory motor and ventilatory output during different modes of assisted mechanical ventilation. Eur Respir J 13:873–882PubMedCrossRef

Ranieri VM, Giuliani R, Mascia L, Grasso S, Petruzzelli V, Puntillo N, Perchiazzi G, Fiore T, Brienza A (1996) Patient-ventilator interaction during acute hypercapnia: pressure-support vs. proportional-assist ventilation. J Appl Physiol 81:426–436PubMed

Wysocki M, Meshaka P, Richard JC, Similowski T (2004) Proportional-assist ventilation compared with pressure-support ventilation during exercise in volunteers with external thoracic restriction. Crit Care Med 32:409–414PubMedCrossRef

10.

Nava S, Bruschi C, Fracchia C, Braschi A, Rubini F (1997) Patient-ventilator interaction and inspiratory effort during pressure support ventilation in patients with different pathologies. Eur Respir J 10:177–183PubMedCrossRef

11.

Younes M, Kun J, Masiowski B, Webster K, Roberts D (2001) A method for noninvasive determination of inspiratory resistance during proportional assist ventilation. Am J Respir Crit Care Med 163:829–839PubMed

12.

Jubran A, Tobin MJ (1997) Pathophysiologic basis of acute respiratory distress in patients who fail a trial of weaning from mechanical ventilation. Am J Respir Crit Care Med 155:906–915PubMed

13.

Giannouli E, Webster K, Roberts D, Younes M (1999) Response of ventilator-dependent patients to different levels of pressure support and proportional assist. Am J Respir Crit Care Med 159:1716–1725PubMed

14.

Passam F, Hoing S, Prinianakis G, Siafakas N, Milic-Emili J, Georgopoulos D (2003) Effect of different levels of pressure support and proportional assist ventilation on breathing pattern, work of breathing and gas exchange in mechanically ventilated hypercapnic COPD patients with acute respiratory failure. Respiration 70:355–361PubMedCrossRef

15.

Ranieri VM, Grasso S, Mascia L, Martino S, Fiore T, Brienza A, Giuliani R (1997) Effects of proportional assist ventilation on inspiratory muscle effort in patients with chronic obstructive pulmonary disease and acute respiratory failure. Anesthesiology 86:79–91PubMedCrossRef

16.

Younes M, Webster K, Kun J, Roberts D, Masiowski B (2001) A method for measuring passive elastance during proportional assist ventilation. Am J Respir Crit Care Med 164:50–60PubMed

17.

Cereda M, Foti G, Marcora B, Gili M, Giacomini M, Sparacino ME, Pesenti A (2000) Pressure support ventilation in patients with acute lung injury. Crit Care Med 28:1269–1275PubMedCrossRef

18.

Putensen C, Zech S, Wrigge H, Zinserling J, Stuber F, Von Spiegel T, Mutz N (2001) Long-term effects of spontaneous breathing during ventilatory support in patients with acute lung injury. Am J Respir Crit Care Med 164:43–49PubMed

19.

Younes M, Ostrowski M, Thompson W, Leslie C, Shewchuk W (2001) Chemical control stability in patients with obstructive sleep apnea. Am J Respir Crit Care Med 163:1181–1190PubMed

20.

Bates JH, Rossi A, Milic-Emili J (1985) Analysis of the behavior of the respiratory system with constant inspiratory flow. J Appl Physiol 58:1840–1848PubMed

21.

Gottfried SB, Higgs BD, Rossi A, Carli F, Mengeot PM, Calverly PM, Zocchi L, Milic-Emili J (1985) Interrupter technique for measurement of respiratory mechanics in anesthetized humans. J Appl Physiol 59:647–652PubMed

22.

Kochi T, Okubo S, Zin WA, Milic-Emili J (1988) Flow and volume dependence of pulmonary mechanics in anesthetized cats. J Appl Physiol 64:441–450PubMed

23.

Georgopoulos D, Mitrouska I, Webster K, Bshouty Z, Younes M (1997) Effects of inspiratory muscle unloading on the response of respiratory motor output to CO2. Am J Respir Crit Care Med 155:2000–2009PubMed

24.

Appendini L, Patessio A, Zanaboni S, Carone M, Gukov B, Donner CF, Rossi A (1994) Physiologic effects of positive end-expiratory pressure and mask pressure support during exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 149:1069–1076PubMed

25.

Bland JM, Altman DG (1986) Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1:307–310PubMed

26.

Douglas NJ, Drummond GB, Sudlow MF (1981) Breathing at low lung volumes and chest strapping: a comparison of lung mechanics. J Appl Physiol 50:650–657PubMed

27.

Kondili E, Prinianakis G, Athanasakis H, Georgopoulos D (2002) Lung emptying in patients with acute respiratory distress syndrome: effects of positive end-expiratory pressure. Eur Respir J 19:811–819PubMedCrossRef

28.

Kondili E, Alexopoulou C, Prinianakis G, Xirouchaki N, Georgopoulos D (2004) Pattern of lung emptying and expiratory resistance in mechanically ventilated patients with chronic obstructive pulmonary disease. Intensive Care Med 30:1311–1318PubMed

29.

Axen K, Haas SS, Haas F, Gaudino D, Haas A (1983) Ventilatory adjustments during sustained mechanical loading in conscious humans. J Appl Physiol 55:1211–1218PubMed

30.

Younes M, Jung D, Puddy A, Giesbrecht G, Sanii R (1990) Role of the chest wall in detection of added elastic loads. J Appl Physiol 68:2241–2245PubMed

31.

Puddy A, Younes M (1991) Effect of slowly increasing elastic load on breathing in conscious humans. J Appl Physiol 70:1277–1283PubMed

32.

Axen K, Haas SS (1979) Range of first-breath ventilatory responses to added mechanical loads in naive men. J Appl Physiol 46:743–751PubMed

33.

Skatrud JB, Dempsey JA (1983) Interaction of sleep state and chemical stimuli in sustaining rhythmic ventilation. J Appl Physiol 55:813–822PubMed

34.

McGregor M, Becklake MR (1961) The relationship of oxygen cost of breathing to respiratory mechanical work and respiratory force. J Clin Invest 40:971–980PubMedCrossRef

35.

Kondili E, Georgopoulos D (2005) New and future developments to improve patient-ventilator interaction. Respir Care Clin N Am 11:319–339PubMedCrossRef

36.

Appendini L, Purro A, Gudjonsdottir M, Baderna P, Patessio A, Zanaboni S, Donner CF, Rossi A (1999) Physiologic response of ventilator-dependent patients with chronic obstructive pulmonary disease to proportional assist ventilation and continuous positive airway pressure. Am J Respir Crit Care Med 159:1510–1517PubMed

37.

Prinianakis G, Kondili E, Georgopoulos D (2003) Effects of the flow waveform method of triggering and cycling on patient-ventilator interaction during pressure support. Intensive Care Med 29:1950–1959PubMedCrossRef

38.

Rebuck A, Slutsky AS (1981) Measurement of ventilatory responses to hypercapnia and hypoxia. In: Hornbein T (ed) Regulation of breathing. Dekker, New York, p 745–772

39.

Mols G, Kessler V, Benzing A, Lichtwarck-Aschoff M, Geiger K, Guttmann J (2001) Is pulmonary resistance constant, within the range of tidal volume ventilation, in patients with ARDS? Br J Anaesth 86:176–182PubMedCrossRef

40.

Younes M (1993) Mechanisms of ventilatory failure. Curr Pulmonol 14:243–292

Title: Respiratory load compensation during mechanical ventilation—proportional assist ventilation with load-adjustable gain factors versus pressure support
Authors: Eumorfia Kondili
George Prinianakis
Christina Alexopoulou
Eleftheria Vakouti
Maria Klimathianaki
Dimitris Georgopoulos
Publication date: 01-05-2006
Publisher: Springer-Verlag
Published in: Intensive Care Medicine / Issue 5/2006
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-006-0110-0

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Respiratory load compensation during mechanical ventilation—proportional assist ventilation with load-adjustable gain factors versus pressure support

Abstract

Rationale

Objectives

Patients and interventions

Measurements and results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Rationale

Objectives

Patients and interventions

Measurements and results

Conclusion

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