Intensive Care Medicine

, Volume 39, Issue 11, pp 2003–2010 | Cite as

Potentially harmful effects of inspiratory synchronization during pressure preset ventilation

  • J. C. M. RichardEmail author
  • A. Lyazidi
  • E. Akoumianaki
  • S. Mortaza
  • R. L. Cordioli
  • J. C. Lefebvre
  • N. Rey
  • L. Piquilloud
  • G. F. Sferrazza-Papa
  • A. Mercat
  • L. Brochard



Pressure preset ventilation (PPV) modes with set inspiratory time can be classified according to their ability to synchronize pressure delivery with patient’s inspiratory efforts (i-synchronization). Non-i-synchronized (like airway pressure release ventilation, APRV), partially i-synchronized (like biphasic airway pressure), and fully i-synchronized modes (like assist-pressure control) can be distinguished. Under identical ventilatory settings across PPV modes, the degree of i-synchronization may affect tidal volume (V T), transpulmonary pressure (P TP), and their variability. We performed bench and clinical studies.


In the bench study, all the PPV modes of five ventilators were tested with an active lung simulator. Spontaneous efforts of −10 cmH2O at rates of 20 and 30 breaths/min were simulated. Ventilator settings were high pressure 30 cmH2O, positive end-expiratory pressure (PEEP) 15 cmH2O, frequency 15 breaths/min, and inspiratory to expiratory ratios (I:E) 1:3 and 3:1. In the clinical studies, data from eight intubated patients suffering from acute respiratory distress syndrome (ARDS) and ventilated with APRV were compared to the bench tests. In four additional ARDS patients, each of the PPV modes was compared.


As the degree of i-synchronization among the different PPV modes increased, mean V T and P TP swings markedly increased while breathing variability decreased. This was consistent with clinical comparison in four ARDS patients. Observational results in eight ARDS patients show low V T and a high variability with APRV.


Despite identical ventilator settings, the different PPV modes lead to substantial differences in V T, P TP, and breathing variability in the presence spontaneous efforts. Clinicians should be aware of the possible harmful effects of i-synchronization especially when high V T is undesirable.


Pressure preset ventilation ARDS APRV BIPAP 



Airway pressure release ventilation


Acute respiratory distress syndrome


Biphasic positive airway pressure


Coefficient of variation


Inspiratory to expiratory ratio


Intensive care unit


Pressure assist control


Positive end-expiratory pressure


Muscular pressure


Pressure preset ventilation


Pressure support


Transpulmonary pressure


Spontaneous respiratory rate


Standard deviation


Tidal volume


Minute ventilation attributed to spontaneous breathing activity


Total minute ventilation



The authors are grateful to Prof. Jordi Mancebo for the critical appraisal of the manuscript. This study was supported by grants from the Société de Réanimation de Langue Française (SRLF) for Nathalie Rey and the Coordenação de Aperfeioçoamento de Pessoal de Nível Superior (CAPES)-Ministry of Education, Brazil (Bolsita da CAPES, Proc. no. BEX-18231-12-8) for Ricardo Cordioli.

Conflicts of interest

We hereby declare that we have no conflict of interest directly related to the manuscript. LB’s research laboratory received grants from several ventilator companies for specific research projects (Maquet, NAVA; Covidien, PAV; Drager, SmartCare; Philips Respironics, NIV; General Electric, FRC).

Supplementary material

134_2013_3032_MOESM1_ESM.docx (535 kb)
Supplementary material 1 (DOCX 534 kb)


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Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2013

Authors and Affiliations

  • J. C. M. Richard
    • 1
    • 2
    • 5
    Email author
  • A. Lyazidi
    • 1
    • 2
  • E. Akoumianaki
    • 1
  • S. Mortaza
    • 3
  • R. L. Cordioli
    • 1
    • 4
  • J. C. Lefebvre
    • 1
  • N. Rey
    • 1
  • L. Piquilloud
    • 3
  • G. F. Sferrazza-Papa
    • 1
  • A. Mercat
    • 3
  • L. Brochard
    • 1
    • 2
    • 6
  1. 1.Intensive Care UnitUniversity Hospital of GenevaGenève 14Switzerland
  2. 2.School of MedicineUniversity of GenevaGenevaSwitzerland
  3. 3.Intensive Care UnitUniversity Hospital of AngersAngersFrance
  4. 4.Hospital Israelita Albert EinsteinSão PauloBrazil
  5. 5.UPRESS EA 38 30Hôpital Universitaire de RouenRouenFrance
  6. 6.INSERM Unit 955, Team 13University Paris-EstCréteilFrance

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