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Impact of Ventilator Adjustment and SedationAnalgesia Practices on Severe Asynchrony in Patients Ventilated in Assist-Control Mode*

Chanques, Gerald MD1–3; Kress, John P. MD1; Pohlman, Anne MSN1; Patel, Shruti MD1; Poston, Jason MD1; Jaber, Samir MD2,3; Hall, Jesse B. MD1

doi: 10.1097/CCM.0b013e31828c2d7a
Clinical Investigations

Objectives: Breath-stacking asynchrony during assist-control-mode ventilation may be associated with increased tidal volume and alveolar pressure that could contribute to ventilator-induced lung injury. Methods to reduce breath stacking have not been well studied. The objective of this investigation was to evaluate 1) which interventions were used by managing clinicians to address severe breath stacking; and 2) how effective these measures were.

Setting: Sixteen-bed medical ICU.

Patients and Interventions: Physiological study in consecutively admitted patients without severe brain injury, who had severe breath stacking defined as an asynchrony index greater than or equal to 10% of total breaths. During 30 minutes before (baseline) and after any intervention employed by the managing clinician, the ventilator flow, airway pressure, and volume/time waveforms were continuously recorded and analyzed to detect normal and stacked breaths. The initial approach taken was assigned to one of three categories: no intervention, increase of sedation–analgesia, or change of ventilator setting. Nonparametric Wilcoxon-Mann-Whitney tests and multiple regression were used for statistical analysis. Quantitative data are presented as median [25–75].

Main Results: Sixty-six of 254 (26%) mechanically ventilated patients exhibited severe breath-stacking asynchrony. A total of 100 30–minute sequences were recorded and analyzed in 30 patients before and after 50 clinical decisions for ongoing management (no intervention, n = 8; increasing sedation/analgesia, n = 16; ventilator adjustment, n = 26). Breath-stacking asynchrony index was 44 [27–87]% at baseline. Compared with baseline, the decrease of asynchrony index was greater after changing the ventilator setting (−99 [−92, −100]%) than after increasing the sedation–analgesia (−41 [−66, 7]%, p < 0.001) or deciding to tolerate the asynchrony (4 [−4, 12]%, p < 0.001). Pressure-support ventilation and increased inspiratory time were independently associated with the reduction of asynchrony index.

Conclusions: Compared with increasing sedation–analgesia, adapting the ventilator to patient breathing effort reduces breath-stacking asynchrony significantly and often dramatically. These results support an algorithm beginning with ventilator adjustment to rationalize the management of severe breath-stacking asynchrony in ICU patients.

1Department of Medicine, Section of Pulmonary & Critical Care, University of Chicago, Chicago, IL.

2Department of Anesthesiology & Critical Care Medicine, University of Montpellier Saint Eloi Hospital, Montpellier, France.

3Unité U1046 de l’Institut National de la Santé et de la Recherche Médicale (INSERM), Université de Montpellier 1, Université de Montpellier 2, Montpellier, France.

* See also p. 2240.

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In addition to institutional funding, Dr. Chanques received a research award from the Société Française d’Anesthésie-Réanimation. Dr. Chanques received grant support from the French Society of Anesthesiology & Critical Care (SFAR) and is employed by the University of Montpellier Hospitals, France. Dr. Kress lectured for Hospira. Dr. Pohlman lectured for B. Braun Inc., ProCE Inc., and the France Foundation. Dr. Poston consulted for CareFirst BCBS; provided expert testimony for Portnoy & Roth PC; received grant support from Hospira; received support for manuscript preparation from BMJ Online; and other: American Physician Institute-board review. Dr. Jaber is employed by the University of Montpellier Hospitals, France. Dr. Hall provided expert testimony for patent and other legal consultation; received grant support from the National Institutes of Health; received royalties from McGraw Hill Publishers; and received support for the development of educational presentations from ACCP. Dr. Patel disclosed that she does not have any potential conflicts of interest.

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© 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins