Critical care (London, England) · 2025
Double cycling with breath-stacking during partial support ventilation in ARDS: Just a feature of natural variability?
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Brito Roberto, Morais Caio C A, Arellano Daniel H, Gajardo Abraham I J, Bruhn Alejandro, Brochard Laurent J, Amato Marcelo B P, Cornejo Rodrigo A
Аннотация
BACKGROUND: Double cycling with breath-stacking (DC/BS) during controlled mechanical ventilation is considered potentially injurious, reflecting a high respiratory drive. During partial ventilatory support, its occurrence might be attributable to physiological variability of breathing patterns, reflecting the response of the mode without carrying specific risks.
METHODS: This secondary analysis of a crossover study evaluated DC/BS events in hypoxemic patients resuming spontaneous breathing in cross-over under neurally adjusted ventilatory assist (NAVA), proportional assist ventilation (PAV +), and pressure support ventilation (PSV). DC/BS was defined as two inspiratory cycles with incomplete exhalation. Measurements included electrical impedance signal, airway pressure, esophageal and gastric pressures, and flow. Breathing variability, dynamic compliance (CLdyn), and end-expiratory lung impedance (EELI) were analyzed.
RESULTS: Twenty patients under assisted breathing, with a median of 9 [5-14] days on mechanical ventilation, were included. DC/BS was attributed to either a single (42%) or two apparent consecutive inspiratory efforts (58%). The median [IQR] incidence of DC/BS was low: 0.6 [0.1-2.6] % in NAVA, 0.0 [0.0-0.4] % in PAV + , and 0.1 [0.0-0.4] % in PSV (p = 0.06). DC/BS events were associated with patient's coefficient of variability for tidal volume (p = 0.014) and respiratory rate (p = 0.011). DC/BS breaths exhibited higher tidal volume, muscular pressure and regional stretch compared to regular breaths. Post-DC/BS cycles frequently exhibited improved EELI and CLdyn, with no evidence of expiratory muscle activation in 63% of cases.
CONCLUSIONS: DC/BS events during partial ventilatory support were infrequent and linked to breathing variability. Their frequency and physiological effects on lung compliance and EELI resemble spontaneous sighs and may not be considered a priori as harmful.
METHODS: This secondary analysis of a crossover study evaluated DC/BS events in hypoxemic patients resuming spontaneous breathing in cross-over under neurally adjusted ventilatory assist (NAVA), proportional assist ventilation (PAV +), and pressure support ventilation (PSV). DC/BS was defined as two inspiratory cycles with incomplete exhalation. Measurements included electrical impedance signal, airway pressure, esophageal and gastric pressures, and flow. Breathing variability, dynamic compliance (CLdyn), and end-expiratory lung impedance (EELI) were analyzed.
RESULTS: Twenty patients under assisted breathing, with a median of 9 [5-14] days on mechanical ventilation, were included. DC/BS was attributed to either a single (42%) or two apparent consecutive inspiratory efforts (58%). The median [IQR] incidence of DC/BS was low: 0.6 [0.1-2.6] % in NAVA, 0.0 [0.0-0.4] % in PAV + , and 0.1 [0.0-0.4] % in PSV (p = 0.06). DC/BS events were associated with patient's coefficient of variability for tidal volume (p = 0.014) and respiratory rate (p = 0.011). DC/BS breaths exhibited higher tidal volume, muscular pressure and regional stretch compared to regular breaths. Post-DC/BS cycles frequently exhibited improved EELI and CLdyn, with no evidence of expiratory muscle activation in 63% of cases.
CONCLUSIONS: DC/BS events during partial ventilatory support were infrequent and linked to breathing variability. Their frequency and physiological effects on lung compliance and EELI resemble spontaneous sighs and may not be considered a priori as harmful.