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Reverse Triggering With and Without Breath Stacking During Pressure-Controlled Ventilation: Exposure Burden and
Song Zhang1, Siyi Yuan1, Elias Baedorf Kassis2
1Drs. Zhang, Yuan, Chi, Huang, Yang, He and Profs. Su and Long are affiliated with Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China.
Background:
Reverse triggering is a complex form of asynchrony with different phenotypes. The exposure burden and clinical outcomes of reverse triggering during pressure-controlled ventilation (PCV) are underexplored. We aimed at determining the incidence of reverse triggering and characterizing the impact of breath-stacking.
Methods:
This was a prospective, observational analysis. Adult subjects with PCV under long-term monitoring were included. The primary outcome was duration of invasive mechanical ventilation. Secondary outcomes included changes in mechanics and tidal volumes associated with breath-stacking, factors correlated with increased frequency of reverse triggering, and testing for thresholds of volume, which could be associated with harm.
Results:
Among 429 subjects with PCV and >24 h of usable waveform recording, 174 subjects (40.6%) were found to have reverse triggering, and 80 subjects had reverse triggering with breath-stacking. Reverse triggering with breath-stacking was associated with higher peak inspiratory pressure (PIP) (15.4 [14.3-17.0] versus 13.7 [11.4, 15.0] cm H2O, P < .001), driving pressure (ΔP) [8.5(7.5,10.0) versus 7.0(5.8,9.0) cm H2O, P < .001] and longer duration of invasive mechanical ventilation [7(3,15) versus 4(2,7) days, P = .015]. Higher level of ΔP (odds ratio [OR] = 1.49, 95% CI: 1.06-2.11, P = .02) and tidal volume (OR = 1.02, 95% CI: 1.01-1.03, P < .001), more fentanyl infusion (OR,1.19, 95% CI: 1.17-1.20, P = .033) and lower value of PaO2/FIO2 (OR = 0.99, 95% CI: 0.98-1.00, P = .02) were risk factors possibly related to reverse triggering with breath-stacking. Receiver operating characteristic analysis suggests that a breath-stacked volume threshold of 141 mL might be associated with prolonged invasive mechanical ventilation.
Conclusions:
Reverse triggering with breath-stacking during PCV was characterized by higher PIP, ΔP, and longer duration of invasive mechanical ventilation. Larger volumes with breath-stacking may be associated with prolonged mechanical ventilation. Fentanyl usage and worse PaO2/FIO2 were risk factors related to reverse triggering with breath-stacking.
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