Assessment of patient-ventilator breath contribution during neurally adjusted ventilatory assist in patients with acute respiratory failure

作者：Liu Ling; Liu Songqiao; Xie Jianfeng; Yang Yi; Slutsky Arthur S; Beck Jennifer; Sinderby Christer; Qiu Haibo^*

来源：Critical Care, 2015, 19(1): 43.

DOI：10.1186/s13054-015-0775-2

Introduction: We previously showed in animals that the ratio of inspired tidal volume (Vt(insp)) to inspiratory peak electrical activity of the diaphragm (EAdi(pk)) can be used to quantify the respective patient and ventilator breath contributions (PVBCs) during neurally adjusted ventilatory assist (NAVA). The PVBC index has not been tested clinically.
Methods: We studied 12 intubated and mechanically ventilated patients with acute respiratory failure and measured EAdi(pk), airway (Paw) and inspiratory esophageal pressure (Pes) and Vt(insp). We applied 11 different NAVA levels, increasing them every 3 minutes in steps of 0.3 cm H2O/mu V from 0 to 3.0 cmH(2)O/mu V. At each NAVA level, one breath was non-assisted (NAVA level 0). PVBC indices were calculated by relating Vt(insp)/EAdi(pk) of the non-assisted breath to Vt(insp)/EAdi(pk) of the assisted breath(s) using one ((PVBC)-P-N1) or the mean value of five preceding assisted breaths ((PVBC)-P-X5). During assisted breaths, inspiratory changes in Pes (Delta Pes) and transpulmonary (Delta Ptp) pressures were used to calculate the relative contribution of patient to total inspiratory lung-distending pressures (Delta Pes/Delta Ptp). Matching of respiratory drive indices and squaring of the PVBC was evaluated for their effect on the correlation between PVBC and Delta Pes/Delta Ptp. Linear regression analysis and Bland-Altman analysis were applied to compare indices.
Results: Using an average of five assisted breaths prior to the non-assisted breath and squaring the PVBC ((PVBC2)-P-X5) improved determination coefficients (P < 0.05), adjusted the regression slope and intercept between PVBC and Delta Pes/Delta Ptp toward identity (P < 0.05) and reduced bias (P < 0.05). Matching EAdi(pk) between non-assisted and assisted breaths within the range of 0.77 to 1.30 improved the relationship between (PVBC2)-P-X5 and Delta Pes/Delta Ptp (P < 0.05) and abolished the need for EAdi normalization in the PVBC calculation (R-2 = 0.96; bias = 0.16 +/- 0.06; precision = 0.33 +/- 0.08 (mean and 95% confidence interval)).
Conclusions: This clinical study confirms previous experimental results showing that the PVBC2 predicts the contribution of the inspiratory muscles versus that of the ventilator during NAVA, when differences in effort (EAdi) between non-assisted and assisted breaths are limited. PVBC could help to quantify and standardize the adjustment of the level of assist, and hence reduce the risks of excessive ventilatory assist in patients.

• 出版日期2015-2-18
• 单位东南大学