Recognizing, quantifying and managing patient-ventilator asynchrony in invasive and noninvasive ventilation

ABSTRACT

Introduction: Patient–ventilator asynchrony may occur with modes of partial ventilatory support. Because this problem is associated with worsened outcomes, identifying and managing asynchronies has been recognized as a relevant clinical problem during both invasive and noninvasive (NIV) mechanical ventilation.

Areas covered: In this review article, we first describe the different forms of patient–ventilator asynchrony and how they are classified and quantified. Then, we show how these asynchronies can be recognized, considering the techniques used to properly detect asynchronies, by either ventilator waveform observation, or through systems based on more complexes mathematical algorithms, by means of adjunctive signals, such as the electrical activity of the diaphragm or esophageal pressure. Finally, we describe the actions that can be undertaken in order to limit the rate of asynchronies during both invasive ventilation and NIV mechanical ventilation, such as modifications of the ventilator mode and/or settings, variation of the sedation regimen (type and doses), and other technical pitfalls.

Expert commentary: Detection of asynchronies is crucial in order to reduce their incidence, adopting adjustments of the ventilator settings, sedation regimen, and other technical pitfalls. It remains to be clarified whether the relationship between high incidence of asynchrony and worsened outcome is causative or just associative.

KEYWORDS:

• Mechanical ventilation
• noninvasive ventilation
• patient–ventilator interaction
• patient–ventilator asynchrony
• ventilator waveforms
• esophageal pressure
• diaphragm electrical activity
• pressure support ventilation
• neurally adjusted ventilatory assist
• proportional assist ventilation

Declaration of interest

P Navalesi contributed to the development of the helmet Next (Castar Next, Intersurgical, Mirandola, Italy), whose license for the patent belongs to Intersurgical S.P.A., and received royalties for that invention. P Navalesi’s research laboratory has received equipment and/or grants from Maquet Critical Care, Intersurgical S.p.A., and Draeger Medical GmbH. They also report receiving honoraria/speaking fees from Maquet Critical Care, Hillrom, Orion Pharma GmbH, Resmed and Philips. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.