Intensive Care Medicine

, Volume 41, Issue 4, pp 633–641 | Cite as

Asynchronies during mechanical ventilation are associated with mortality

  • Lluís Blanch
  • Ana Villagra
  • Bernat Sales
  • Jaume Montanya
  • Umberto Lucangelo
  • Manel Luján
  • Oscar García-Esquirol
  • Encarna Chacón
  • Anna Estruga
  • Joan C. Oliva
  • Alberto Hernández-Abadia
  • Guillermo M. Albaiceta
  • Enrique Fernández-Mondejar
  • Rafael Fernández
  • Josefina Lopez-Aguilar
  • Jesús Villar
  • Gastón Murias
  • Robert M. Kacmarek



This study aimed to assess the prevalence and time course of asynchronies during mechanical ventilation (MV).


Prospective, noninterventional observational study of 50 patients admitted to intensive care unit (ICU) beds equipped with Better Care™ software throughout MV. The software distinguished ventilatory modes and detected ineffective inspiratory efforts during expiration (IEE), double-triggering, aborted inspirations, and short and prolonged cycling to compute the asynchrony index (AI) for each hour. We analyzed 7,027 h of MV comprising 8,731,981 breaths.


Asynchronies were detected in all patients and in all ventilator modes. The median AI was 3.41 % [IQR 1.95–5.77]; the most common asynchrony overall and in each mode was IEE [2.38 % (IQR 1.36–3.61)]. Asynchronies were less frequent from 12 pm to 6 am [1.69 % (IQR 0.47–4.78)]. In the hours where more than 90 % of breaths were machine-triggered, the median AI decreased, but asynchronies were still present. When we compared patients with AI > 10 vs AI ≤ 10 %, we found similar reintubation and tracheostomy rates but higher ICU and hospital mortality and a trend toward longer duration of MV in patients with an AI above the cutoff.


Asynchronies are common throughout MV, occurring in all MV modes, and more frequently during the daytime. Further studies should determine whether asynchronies are a marker for or a cause of mortality.


Patient–ventilator asynchrony Mechanical ventilation Mortality Respiratory monitoring 



The authors thank Mercè Ruiz and Mr. John Giba for their invaluable support in editing the manuscript. This study was financially supported by ISCIII PI09/91074, PI13/02204, CIBER Enfermedades Respiratorias, Fundación Mapfre, Fundació Parc Taulí, Plan Avanza TSI-020302-2008-38, MCYIN and MITYC (Spain). No funding organization or sponsor was involved in the design or conduct of the study, in the collection, management, analysis, or interpretation of the data, or in the preparation, review, or approval of the manuscript..

Conflicts of interest

Blanch, Sales, and Murias are inventors of one Corporació Sanitaria Parc Taulí owned US patent: “Method and system for managed related patient parameters provided by a monitoring device,” US Patent No. 12/538,940. Blanch, Sales, Murias, and Lucangelo own stock options of BetterCare S.L., which is a research and development spinoff of Corporació Sanitària Parc Taulí (Spain). Kacmarek is a consultant for Covidien, has received research grants from Covidien and Hollister, and has received honoraria from Maquet for lectures. Villar has received research grants from Maquet. Montanya, Villagrá, Luján, Garcia-Esquirol, Chacón, Estruga, Oliva, Hernandez Abadia, Albaiceta, Fernandez-Mondejar, López-Aguilar and Fernandez have no conflicts of interest.

Supplementary material

134_2015_3692_MOESM1_ESM.doc (298 kb)
Supplementary material 1 (DOC 298 kb)


  1. 1.
    Schmidt M, Demoule A, Polito A, Porchet R, Aboab J, Siami S, Morelot-Panzini C, Similowski T, Sharshar T (2011) Dyspnea in mechanically ventilated critically ill patients. Crit Care Med 39:2059–2065CrossRefPubMedGoogle Scholar
  2. 2.
    Gilstrap D, MacIntyre N (2013) Patient–ventilator interactions. Implications for clinical management. Am J Respir Crit Care Med 188:1058–1068CrossRefPubMedGoogle Scholar
  3. 3.
    Murias G, Villagra A, Blanch L (2013) Patient–ventilator dyssynchrony during assisted invasive mechanical ventilation. Minerva Anestesiol 79:434–444PubMedGoogle Scholar
  4. 4.
    Vitacca M, Bianchi L, Zanotti E, Vianello A, Barbano L, Porta R, Clini E (2004) Assessment of physiologic variables and subjective comfort under different levels of pressure support ventilation. Chest 126:851–859CrossRefPubMedGoogle Scholar
  5. 5.
    Schmidt M, Banzett RB, Raux M, Morelot-Panzini C, Dangers L, Similowski T, Demoule A (2014) Unrecognized suffering in the ICU: addressing dyspnea in mechanically ventilated patients. Intensive Care Med 40:1–10CrossRefPubMedCentralPubMedGoogle Scholar
  6. 6.
    Hansen-Flaschen JH, Brazinsky S, Basile C, Lanken PN (1991) Use of sedating drugs and neuromuscular blocking agents in patients requiring mechanical ventilation for respiratory failure. A national survey. JAMA 266:2870–2875CrossRefPubMedGoogle Scholar
  7. 7.
    de Wit M, Pedram S, Best AM, Epstein SK (2009) Observational study of patient–ventilator asynchrony and relationship to sedation level. J Crit Care 24:74–80CrossRefPubMedCentralPubMedGoogle Scholar
  8. 8.
    Shehabi Y, Chan L, Kadiman S, Alias A, Ismail WN, Tan MA, Khoo TM, Ali SB, Saman MA, Shaltut A, Tan CC, Yong CY, Bailey M (2013) Sedation depth and long-term mortality in mechanically ventilated critically ill adults: a prospective longitudinal multicentre cohort study. Intensive Care Med 39:910–918CrossRefPubMedCentralPubMedGoogle Scholar
  9. 9.
    de Wit M, Miller KB, Green DA, Ostman HE, Gennings C, Epstein SK (2009) Ineffective triggering predicts increased duration of mechanical ventilation. Crit Care Med 37:2740–2745CrossRefPubMedGoogle Scholar
  10. 10.
    Thille AW, Rodriguez P, Cabello B, Lellouche F, Brochard L (2006) Patient–ventilator asynchrony during assisted mechanical ventilation. Intensive Care Med 32:1515–1522CrossRefPubMedGoogle Scholar
  11. 11.
    Slutsky AS (2010) Neuromuscular blocking agents in ARDS. N Engl J Med 363:1176–1180CrossRefPubMedGoogle Scholar
  12. 12.
    Vassilakopoulos T, Petrof BJ (2004) Ventilator-induced diaphragmatic dysfunction. Am J Respir Crit Care Med 169:336–341CrossRefPubMedGoogle Scholar
  13. 13.
    Tobin MJ, Jubran A, Laghi F (2013) Fighting the ventilator. In: Tobin MJ (ed) Principles and practice of mechanical ventilation. McGraw-Hill, New York, pp 1237–1259 Google Scholar
  14. 14.
    Alexopoulou C, Kondili E, Plataki M, Georgopoulos D (2013) Patient–ventilator synchrony and sleep quality with proportional assist and pressure support ventilation. Intensive Care Med 39:1040–1047CrossRefPubMedGoogle Scholar
  15. 15.
    Chao DC, Scheinhorn DJ, Stearn-Hassenpflug M (1997) Patient–ventilator trigger asynchrony in prolonged mechanical ventilation. Chest 112:1592–1599CrossRefPubMedGoogle Scholar
  16. 16.
    Colombo D, Cammarota G, Alemani M, Carenzo L, Barra FL, Vaschetto R, Slutsky AS, Della Corte F, Navalesi P (2011) Efficacy of ventilator waveforms observation in detecting patient–ventilator asynchrony. Crit Care Med 39:2452–2457CrossRefPubMedGoogle Scholar
  17. 17.
    Blanch L, Sales B, Montanya J, Lucangelo U, Garcia-Esquirol O, Villagra A, Chacon E, Estruga A, Borelli M, Burgueno MJ, Oliva JC, Fernandez R, Villar J, Kacmarek R, Murias G (2012) Validation of the Better Care® system to detect ineffective efforts during expiration in mechanically ventilated patients: a pilot study. Intensive Care Med 38:772–780CrossRefPubMedGoogle Scholar
  18. 18.
    Chacon E, Estruga A, Murias G, Sales B, Montanya J, Lucangelo U, Garcia-Esquirol O, Villagra A, Villar J, Kacmarek RM, Burgueno MJ, Blanch L, Jam R (2012) Nurses’ detection of ineffective inspiratory efforts during mechanical ventilation. Am J Crit Care 21:e89–e93CrossRefPubMedGoogle Scholar
  19. 19.
    Villagra A, Sales B, Montanya J, Fernandez R, Chacon E, Estruga A, Lucangello U, Garcia-Esquiro O, Albaiceta GM, Hernandez-Abadia A, Mondejar EF, Burgueno MJ, Oliva JC, Villar J, Kacmareck RB, Murias G, Blanch L (2012) Prevalence of patient–ventilator asynchrony in critically ill patients. Intensive Care Med 38:S265–S265Google Scholar
  20. 20.
    Villar J, Blanco J, Anon JM, Santos-Bouza A, Blanch L, Ambros A, Gandia F, Carriedo D, Mosteiro F, Basaldua S, Fernandez RL, Kacmarek RM (2011) The ALIEN study: incidence and outcome of acute respiratory distress syndrome in the era of lung protective ventilation. Intensive Care Med 37:1932–1941CrossRefPubMedGoogle Scholar
  21. 21.
    Parthasarathy S, Jubran A, Tobin MJ (1998) Cycling of inspiratory and expiratory muscle groups with the ventilator in airflow limitation. Am J Respir Crit Care Med 158:1471–1478CrossRefPubMedGoogle Scholar
  22. 22.
    Correger E, Murias G, Chacon E, Estruga A, Sales B, Lopez-Aguilar J, Montanya J, Lucangelo U, Garcia-Esquirol O, Villagra A, Villar J, Kacmarek RM, Burgueno MJ, Blanch L (2012) Interpretation of ventilator curves in patients with acute respiratory failure. Med Intensiva 36:294–306CrossRefPubMedGoogle Scholar
  23. 23.
    Georgopoulos D, Prinianakis G, Kondili E (2006) Bedside waveforms interpretation as a tool to identify patient–ventilator asynchronies. Intensive Care Med 32:34–47CrossRefPubMedGoogle Scholar
  24. 24.
    Fanfulla F, Delmastro M, Berardinelli A, Lupo ND, Nava S (2005) Effects of different ventilator settings on sleep and inspiratory effort in patients with neuromuscular disease. Am J Respir Crit Care Med 172:619–624CrossRefPubMedGoogle Scholar
  25. 25.
    Thille AW, Cabello B, Galia F, Lyazidi A, Brochard L (2008) Reduction of patient–ventilator asynchrony by reducing tidal volume during pressure-support ventilation. Intensive Care Med 34:1477–1486CrossRefPubMedGoogle Scholar
  26. 26.
    Chanques G, Kress JP, Pohlman A, Patel S, Poston J, Jaber S, Hall JB (2013) Impact of ventilator adjustment and sedation-analgesia practices on severe asynchrony in patients ventilated in assist-control mode. Crit Care Med 41:2177–2187CrossRefPubMedGoogle Scholar
  27. 27.
    Beck J, Gottfried SB, Navalesi P, Skrobik Y, Comtois N, Rossini M, Sinderby C (2001) Electrical activity of the diaphragm during pressure support ventilation in acute respiratory failure. Am J Respir Crit Care Med 164:419–424CrossRefPubMedGoogle Scholar
  28. 28.
    Akoumianaki E, Lyazidi A, Rey N, Matamis D, Perez-Martinez N, Giraud R, Mancebo J, Brochard L, Marie Richard JC (2013) Mechanical ventilation-induced reverse-triggered breaths: a frequently unrecognized form of neuromechanical coupling. Chest 143:927–938CrossRefPubMedGoogle Scholar
  29. 29.
    Vignaux L, Vargas F, Roeseler J, Tassaux D, Thille AW, Kossowsky MP, Brochard L, Jolliet P (2009) Patient–ventilator asynchrony during non-invasive ventilation for acute respiratory failure: a multicenter study. Intensive Care Med 35:840–846CrossRefPubMedGoogle Scholar
  30. 30.
    Cordoba-Izquierdo A, Drouot X, Thille AW, Galia F, Roche-Campo F, Schortgen F, Prats-Soro E, Brochard L (2013) Sleep in hypercapnic critical care patients under noninvasive ventilation: conventional versus dedicated ventilators. Crit Care Med 41:60–68CrossRefPubMedGoogle Scholar
  31. 31.
    Fanfulla F, Taurino AE, Lupo ND, Trentin R, D’Ambrosio C, Nava S (2007) Effect of sleep on patient/ventilator asynchrony in patients undergoing chronic non-invasive mechanical ventilation. Respir Med 101:1702–1707CrossRefPubMedGoogle Scholar
  32. 32.
    Vaschetto R, Cammarota G, Colombo D, Longhini F, Grossi F, Giovanniello A, Della Corte F, Navalesi P (2014) Effects of propofol on patient–ventilator synchrony and interaction during pressure support ventilation and neurally adjusted ventilatory assist. Crit Care Med 42:74–82CrossRefPubMedGoogle Scholar
  33. 33.
    Hirose L, Nosaka K, Newton M, Laveder A, Kano M, Peake J, Suzuki K (2004) Changes in inflammatory mediators following eccentric exercise of the elbow flexors. Exerc Immunol Rev 10:75–90PubMedGoogle Scholar
  34. 34.
    Hotchkiss JR Jr, Blanch L, Murias G, Adams AB, Olson DA, Wangensteen OD, Leo PH, Marini JJ (2000) Effects of decreased respiratory frequency on ventilator-induced lung injury. Am J Respir Crit Care Med 161:463–468CrossRefPubMedGoogle Scholar
  35. 35.
    Esteban A, Frutos-Vivar F, Muriel A, Ferguson ND, Penuelas O, Abraira V, Raymondos K, Rios F, Nin N, Apezteguia C, Violi DA, Thille AW, Brochard L, Gonzalez M, Villagomez AJ, Hurtado J, Davies AR, Du B, Maggiore SM, Pelosi P, Soto L, Tomicic V, D’Empaire G, Matamis D, Abroug F, Moreno RP, Soares MA, Arabi Y, Sandi F, Jibaja M, Amin P, Koh Y, Kuiper MA, Bulow HH, Zeggwagh AA, Anzueto A (2013) Evolution of mortality over time in patients receiving mechanical ventilation. Am J Respir Crit Care Med 188:220–230CrossRefPubMedGoogle Scholar
  36. 36.
    Papazian L, Forel JM, Gacouin A, Penot-Ragon C, Perrin G, Loundou A, Jaber S, Arnal JM, Perez D, Seghboyan JM, Constantin JM, Courant P, Lefrant JY, Guerin C, Prat G, Morange S, Roch A (2010) Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med 363:1107–1116CrossRefPubMedGoogle Scholar
  37. 37.
    Herridge MS, Tansey CM, Matte A, Tomlinson G, Diaz-Granados N, Cooper A, Guest CB, Mazer CD, Mehta S, Stewart TE, Kudlow P, Cook D, Slutsky AS, Cheung AM (2011) Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med 364:1293–1304CrossRefPubMedGoogle Scholar
  38. 38.
    Clement KC, Heulitt MJ (2013) Not all types of asynchrony are created equal. Intensive Care Med 39:338CrossRefPubMedGoogle Scholar
  39. 39.
    Lellouche F, Bouchard PA, Simard S, L’Her E, Wysocki M (2013) Evaluation of fully automated ventilation: a randomized controlled study in post-cardiac surgery patients. Intensive Care Med 39:463–471CrossRefPubMedGoogle Scholar
  40. 40.
    Richard JC, Lyazidi A, Akoumianaki E, Mortaza S, Cordioli RL, Lefebvre JC, Rey N, Piquilloud L, Sferrazza Papa GF, Mercat A, Brochard L (2013) Potentially harmful effects of inspiratory synchronization during pressure preset ventilation. Intensive Care Med 39:2003–2010CrossRefPubMedGoogle Scholar
  41. 41.
    Sinderby C, Liu S, Colombo D, Camarotta G, Slutsky AS, Navalesi P, Beck J (2013) An automated and standardized neural index to quantify patient–ventilator interaction. Crit Care 17:R239CrossRefPubMedCentralPubMedGoogle Scholar
  42. 42.
    Akoumianaki E, Maggiore SM, Valenza F, Bellani G, Jubran A, Loring SH, Pelosi P, Talmor D, Grasso S, Chiumello D, Guerin C, Patroniti N, Ranieri VM, Gattinoni L, Nava S, Terragni PP, Pesenti A, Tobin M, Mancebo J, Brochard L (2014) The application of esophageal pressure measurement in patients with respiratory failure. Am J Respir Crit Care Med 189:520–531CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2015

Authors and Affiliations

  • Lluís Blanch
    • 1
    • 2
    • 3
  • Ana Villagra
    • 1
    • 2
  • Bernat Sales
    • 2
    • 3
  • Jaume Montanya
    • 2
    • 3
  • Umberto Lucangelo
    • 4
  • Manel Luján
    • 2
    • 5
  • Oscar García-Esquirol
    • 1
    • 3
  • Encarna Chacón
    • 1
  • Anna Estruga
    • 1
  • Joan C. Oliva
    • 3
  • Alberto Hernández-Abadia
    • 6
  • Guillermo M. Albaiceta
    • 2
    • 7
    • 8
  • Enrique Fernández-Mondejar
    • 9
  • Rafael Fernández
    • 2
    • 10
  • Josefina Lopez-Aguilar
    • 1
    • 2
    • 3
  • Jesús Villar
    • 2
    • 11
  • Gastón Murias
    • 12
  • Robert M. Kacmarek
    • 13
    • 14
  1. 1.Critical Care Center, Hospital de Sabadell, Corporació Sanitaria Universitària Parc TaulíUniversitat Autònoma de BarcelonaSabadellSpain
  2. 2.CIBER Enfermedades RespiratoriasISCIIIMadridSpain
  3. 3.Fundació Parc Taulí, Corporació Sanitaria Universitària Parc TaulíUniversitat Autònoma de BarcelonaSabadellSpain
  4. 4.Department of Perioperative Medicine, Intensive Care and Emergency, Cattinara HospitalTrieste UniversityTriesteItaly
  5. 5.Department of Pneumology, Hospital de Sabadell, Corporació Sanitària Universitària Parc TaulíUniversitat Autònoma de BarcelonaSabadellSpain
  6. 6.Hospital Central de la Defensa Gomez UllaMadridSpain
  7. 7.Department of Functional BiologyUniversidad de OviedoOviedoSpain
  8. 8.Department of Critical CareHospital Central de AsturiasOviedoSpain
  9. 9.Department of Emergency and Critical Care Medicine, Hospital Virgen de las NievesUniversidad de GranadaGranadaSpain
  10. 10.Servei de Medicina Intensiva, Fundacio AlthaiaUniversitat Internacional de CatalunyaManresaSpain
  11. 11.Research Unit, Multidisciplinary Organ Dysfunction Evaluation Research Network (MODERN)Hospital Universitario Dr. NegrínLas Palmas De Gran CanariaSpain
  12. 12.Clínica Bazterrica y Clínica Santa IsabelBuenos AiresArgentina
  13. 13.Department of Respiratory CareMassachusetts General HospitalBostonUSA
  14. 14.Department of AnesthesiologyHarvard Medical SchoolBostonUSA

Personalised recommendations