Abstract
Pressure support ventilation (PSV) is the most commonly used mode of assisted ventilation in the intensive care unit. Setting the ventilator in PSV mode appears to be easy, yet optimizing patient-ventilator interaction in terms of matching a patient’s ventilatory demands with the level of assist, and the neural inspiratory time (Ti) with the mechanical Ti, is particularly challenging. Excessive assist can often occur during PSV, leading to weak or ineffective efforts and periodic breathing, promoting diaphragmatic injury and prolonged mechanical ventilation. Additionally, mismatch between mechanical and neural Ti almost invariably occurs, leading to expiratory asynchronies and prohibiting accurate measurement of driving pressure, placing patients with high respiratory drive at risk of lung injury. Three types of problem hindering patient-ventilator interaction in PSV can be identified. First, factors inherent to the operation of PSV, which include the limited dependence, and thus matching, between mechanical Ti and neural Ti, and the delivery, after ventilator triggering and independently of the patient’s effort, of a minimum tidal volume, depending on the level of pressure support. Second, the response pattern of the control-of-breathing system to changes in ventilatory demands, which is mediated mainly by changes in effort and minimally by changes in respiratory rate. Lastly, the lack of clinical signs of excessive ventilatory assist, and automated monitoring tools, make optimization of patient-ventilator interaction during PSV difficult. Understanding the challenges of PSV can facilitate prompt recognition and management of the problems it may create, and help provide lung- and diaphragm-protective ventilation during PSV.
This is a preview of subscription content, log in via an institution to check access.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
van Haren F, Pham T, Brochard L, et al. Spontaneous breathing in early acute respiratory distress syndrome: insights from the large observational study to UNderstand the Global Impact of Severe Acute Respiratory FailurE Study. Crit Care Med. 2019;47:229–38.
Thille AW, Lyazidi A, Richard JCM, Galia F, Brochard L. A bench study of intensive-care-unit ventilators: new versus old and turbine-based versus compressed gas-based ventilators. Intensive Care Med. 2009;35:1368–76.
Akoumianaki E, Prinianakis G, Kondili E, Malliotakis P, Georgopoulos D. Physiologic comparison of neurally adjusted ventilator assist, proportional assist and pressure support ventilation in critically ill patients. Respir Physiol Neurobiol. 2014;203:82–9.
Prinianakis G, Kondili E, Georgopolous D. Patient-ventilator interaction: an overview. Respir Care Clin N Am. 2005;11:201–24.
Prinianakis G, Plataki M, Kondili E, Klimathianaki M, Vaporidi K, Georgopoulos D. Effects of relaxation of inspiratory muscles on ventilator pressure during pressure support. Intensive Care Med. 2008;34:70–4.
Georgopoulos D, Mitrouska I, Bshouty Z, Webster K, Patakas D, Younes M. Respiratory response to CO2 during pressure-support ventilation in conscious normal humans. Am J Respir Crit Care Med. 1997;156:146–54.
Lilitsis E, Stamatopoulou V, Andrianakis E, et al. Inspiratory effort and breathing pattern change in response to varying the assist level: a physiological study. Respir Physiol Neurobiol. 2020;280:103474.
Akoumianaki E, Vaporidi K, Georgopoulos D. The injurious effects of elevated or nonelevated respiratory rate during mechanical ventilation. Am J Respir Crit Care Med. 2019;199:149–57.
Randerath W, Schiza S, Deleanu O, Pepin JL. Central sleep apnoea and periodic breathing in heart failure: prognostic significance and treatment options. Eur Respir Rev. 2019;28:190084.
Meza S, Mendez M, Ostrowski M, Younes M. Susceptibility to periodic breathing with assisted ventilation during sleep in normal subjects. J Appl Physiol. 1985;1998(85):1929–40.
Parthasarathy S, Tobin MJ. Effect of ventilator mode on sleep quality in critically ill patients. Am J Respir Crit Care Med. 2002;166:1423–9.
Levine S, Nguyen T, Taylor N, et al. Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. N Engl J Med. 2008;358:1327–35.
Hudson MB, Smuder AJ, Nelson WB, Bruells CS, Levine S, Powers SK. Both high level pressure support ventilation and controlled mechanical ventilation induce diaphragm dysfunction and atrophy. Crit Care Med. 2012;40:1254–60.
Urner M, Mitsakakis N, Vorona S, et al. Identifying subjects at risk for diaphragm atrophy during mechanical ventilation using routinely available clinical data. Respir Care. 2021;66:551–8.
Goligher EC, Fan E, Herridge MS, et al. Evolution of diaphragm thickness during mechanical ventilation. Impact of inspiratory effort. Am J Respir Crit Care Med. 2015;192:1080–8.
Zambon M, Beccaria P, Matsuno J, et al. Mechanical ventilation and diaphragmatic atrophy in critically ill patients: an ultrasound study. Crit Care Med. 2016;44:1347–52.
Goligher EC, Dres M, Fan E, et al. Mechanical ventilation-induced diaphragm atrophy strongly impacts clinical outcomes. Am J Respir Crit Care Med. 2018;197:204–13.
Carteaux G, Cordoba-Izquierdo A, Lyazidi A, Heunks L, Thille AW, Brochard L. Comparison between neurally adjusted ventilatory assist and pressure support ventilation levels in terms of respiratory effort. Crit Care Med. 2016;44:503–11.
Terzi N, Pelieu I, Guittet L, et al. Neurally adjusted ventilatory assist in patients recovering spontaneous breathing after acute respiratory distress syndrome: physiological evaluation. Crit Care Med. 2010;38:1830–7.
Vaporidi K, Babalis D, Chytas A, et al. Clusters of ineffective efforts during mechanical ventilation: impact on outcome. Intensive Care Med. 2017;43:184–91.
Blanch L, Villagra A, Sales B, et al. Asynchronies during mechanical ventilation are associated with mortality. Intensive Care Med. 2015;41:633–41.
Vaporidi K, Akoumianaki E, Telias I, Goligher EC, Brochard L, Georgopoulos D. Respiratory drive in critically ill patients. Pathophysiology and clinical implications. Am J Respir Crit Care Med. 2020;201:20–32.
Goligher EC, Dres M, Patel BK, et al. Lung- and diaphragm-protective ventilation. Am J Respir Crit Care Med. 2020;202:950–61.
Yamada Y, Du HL. Analysis of the mechanisms of expiratory asynchrony in pressure support ventilation: a mathematical approach. J Appl Physiol (1985). 2000;88:2143–50.
Georgopoulos D, Prinianakis G, Kondili E. Bedside waveforms interpretation as a tool to identify patient-ventilator asynchronies. Intensive Care Med. 2006;32:34–47.
Liu L, Xu XT, Yu Y, Sun Q, Yang Y, Qiu HB. Neural control of pressure support ventilation improved patient-ventilator synchrony in patients with different respiratory system mechanical properties: a prospective, crossover trial. Chin Med J. 2021;134:281–91.
Karageorgos V, Proklou A, Vaporidi K. Lung and diaphragm protective ventilation: a synthesis of recent data. Expert Rev Respir Med. 2022;16:375–90.
Yoshida T, Fujino Y, Amato MBP, Kavanagh BP. Fifty years of research in ARDS. Spontaneous breathing during mechanical ventilation. Risks, mechanisms, and management. Am J Respir Crit Care Med. 2017;195:985–92.
Brochard L, Slutsky A, Pesenti A. Mechanical ventilation to minimize progression of lung injury in acute respiratory failure. Am J Respir Crit Care Med. 2017;195:438–42.
Jiang TX, Reid WD, Belcastro A, Road JD. Load dependence of secondary diaphragm inflammation and injury after acute inspiratory loading. Am J Respir Crit Care Med. 1998;157:230–6.
Vaporidi K. NAVA and PAV+ for lung and diaphragm protection. Curr Opin Crit Care. 2020;26:41–6.
Mascheroni D, Kolobow T, Fumagalli R, Moretti MP, Chen V, Buckhold D. Acute respiratory failure following pharmacologically induced hyperventilation: an experimental animal study. Intensive Care Med. 1988;15:8–14.
Vaporidi K, Psarologakis C, Proklou A, et al. Driving pressure during proportional assist ventilation: an observational study. Ann Intensive Care. 2019;9:1.
Amato MBP, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. 2015;372:747–55.
Soundoulounaki S, Akoumianaki E, Kondili E, et al. Airway pressure morphology and respiratory muscle activity during end-inspiratory occlusions in pressure support ventilation. Crit Care. 2020;24:467.
Telias I, Spadaro S. Techniques to monitor respiratory drive and inspiratory effort. Curr Opin Crit Care. 2020;26:3–10.
Bertoni M, Telias I, Urner M, et al. A novel non-invasive method to detect excessively high respiratory effort and dynamic transpulmonary driving pressure during mechanical ventilation. Crit Care. 2019;23:346.
Tobin MJ, Jubran A, Laghi F. Respiratory drive measurements do not signify conjectural patient self-inflicted lung injury. Am J Respir Crit Care Med. 2021;203:142–3.
Proklou A, Papadakis E, Kondili E, et al. Ventilatory ratio threshold for unassisted breathing: a retrospective exploratory analysis. Respir Care. 2021;66:1699–703.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2023 The Author(s), under exclusive license to Springer Nature Switzerland AG
About this chapter
Cite this chapter
Proklou, A., Karageorgos, V., Vaporidi, K. (2023). The Potential Risks of Pressure Support Ventilation. In: Vincent, JL. (eds) Annual Update in Intensive Care and Emergency Medicine 2023. Annual Update in Intensive Care and Emergency Medicine. Springer, Cham. https://doi.org/10.1007/978-3-031-23005-9_16
Download citation
DOI: https://doi.org/10.1007/978-3-031-23005-9_16
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-031-23004-2
Online ISBN: 978-3-031-23005-9
eBook Packages: MedicineMedicine (R0)