Patient-ventilator interaction

Patient-ventilator interaction has been the focus of increasing attention from both manufacturers and researchers during the last 25 years. There is now compelling evidence that passive (controlled) mechanical ventilation leads to respiratory muscle dysfunction and atrophy, prolonging the need for ventilatory support and predisposing to a number of adverse patient outcomes. Although there is consensus that the respiratory muscles should retain some activity during acute respiratory failure, patient-ventilator asynchrony is now recognized as a cause of ineffective ventilation, impaired gas exchange, lung overdistention, increased work of breathing, and patient discomfort. Far more common than previously recognized, it also predisposes to respiratory muscle dysfunction and other complications, leads to excessive use of sedation, increases the duration of ventilatory support, and interferes with weaning. Appropriate recognition and management of patient-ventilator asynchrony require bedside assessment of ventilator graphics as well as direct patient observation. Among currently available ventilation modes and approaches, none has been shown to be clearly superior to all the others with respect to patient-ventilator interaction, and strongly held preferences among investigators have led to controversy and difficulties in carrying out appropriate studies evaluating them. As a result, marked practice variation exists among different specialties as well as in different institutions and geographical areas. The respected authorities on mechanical ventilation who participated in this conference differed in the modes they preferred but agreed that proper understanding and use according to the individual patient's needs are more important than which mode is chosen. Conference participants discussed the determinants, manifestations, and epidemiology of patient-ventilator asynchrony, and described and compared several ventilation modes aimed specifically at preventing and ameliorating it. The papers arising from these discussions represent the most thorough examination of this important aspect of respiratory care yet published.