Intensive Care Medicine

, Volume 42, Issue 6, pp 1058–1061 | Cite as

Does this ventilated patient have asynchronies? Recognizing reverse triggering and entrainment at the bedside

  • Gastón Murias
  • Candelaria de Haro
  • Lluis BlanchEmail author
What's New in Intensive Care

Reverse triggering is a frequently under-recognized form of patient–ventilatory asynchrony in which the patient’s respiratory center is activated in response to a passive insufflation of the lungs. It can be detected at the bedside by observing airway pressure and airflow waveforms.

Figure  1a and video 1 (in the electronic supplementary material, ESM) show airway pressure and flow waveforms from a patient ventilated in volume-control mode. The breaths are almost certainly machine triggered because no perturbation in airway pressure can be seen at the beginning of the breath. At first sight, the records seem quite normal. However, a closer look shows that breaths marked with arrows are slightly different from other breaths. The airway pressure waveform shows a fall during the inspiratory plateau. Provided there are no air leaks, the amount of gas inside the respiratory system is constant (both the inspiratory and expiratory valves are closed), and a decrease in airway pressure denotes...


Airway Pressure Peak Expiratory Flow Pressure Waveform Inspiratory Muscle Flow Waveform 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Financial support

This work was funded by projects ISCIII PI09/91074 and PI13/02204 integrated into the Plan Estatal de I+D+I 2013–2016 and funded by the ISCIII-Subdirección General de Evaluación y Fomento de la Investigación el Fondo Europeo de Desarrollo Regional (FEDER), CIBER Enfermedades Respiratorias, Fundación Mapfre, Fundació Parc Taulí, Plan Avanza TSI-020302-2008-38, MCYIN and MITYC (Spain).

Compliance with ethical standards

Conflicts of interest

Murias and Blanch 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. Murias and Blanch own stock options of BetterCare S.L., which is a research and development spin-off of Corporació Sanitària Parc Taulí (Spain). Candelaria de Haro has no conflicts of interest.

Supplementary material

Supplementary material 1 (MP4 17086 kb)

Supplementary material 2 (MP4 15667 kb)

Supplementary material 3 (MP4 16313 kb)

Supplementary material 4 (MP4 17083 kb)

134_2015_4177_MOESM5_ESM.docx (146 kb)
Supplementary material 5 (DOCX 146 kb)


  1. 1.
    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
  2. 2.
    Petrillo GA, Glass L, Trippenbach T (1983) Phase locking of the respiratory rhythm in cats to a mechanical ventilator. Can J Physiol Pharmacol 61:599–607CrossRefPubMedGoogle Scholar
  3. 3.
    Graves C, Glass L, Laporta D, Meloche R, Grassino A (1986) Respiratory phase locking during mechanical ventilation in anesthetized human subjects. Am J Physiol 250:R902–R909PubMedGoogle Scholar
  4. 4.
    Akoumianaki E, Lyazidi A, Rey N, Matamis D, Perez-Martinez N, Giraud R, Mancebo J, Brochard L, Richard JCM (2013) Mechanical ventilation-induced reverse-triggered breaths: a frequently unrecognized form of neuromechanical coupling. Chest 143:927–938CrossRefPubMedGoogle Scholar
  5. 5.
    Vibert JF, Caille D, Segundo JP (1981) Respiratory oscillator entrainment by periodic vagal afferentes: an experimental test of a model. Biol Cybern 41:119–130CrossRefPubMedGoogle Scholar
  6. 6.
    Ainsworth DM, Smith CA, Henderson KS, Dempsey JA (1996) Breathing during exercise in dogs–passive or active? J Appl Physiol (1985) 81:586–595Google Scholar
  7. 7.
    Bramble DM, Carrier DR (1983) Running and breathing in mammals. Science 219(4582):251–256CrossRefPubMedGoogle Scholar
  8. 8.
    Iscoe S (1981) Respiratory and stepping frequencies in conscious exercising cats. J Appl Physiol 51:835–839PubMedGoogle Scholar
  9. 9.
    Krogh A, Lindhard J (1913) The regulation of respiration and circulation during the initial stages of muscular work. J Physiol 47:112–136CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Funk GD, Milsom WK, Steeves JD (1992) Coordination of wingbeat and respiration in the Canada goose. I. Passive wing flapping. J Appl Physiol (1985) 73:1014–1024Google Scholar
  11. 11.
    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, Burgueño MJ, Blanch L (2012) Interpretation of ventilator curves in patients with acute respiratory failure. Med Intensiva 36:294–306CrossRefPubMedGoogle Scholar
  12. 12.
    Simon PM, Habel AM, Daubenspeck JA, Leiter JC (2000) Vagal feedback in the entrainment of respiration to mechanical ventilation in sleeping humans. J Appl Physiol (1985) 89:760–769Google Scholar
  13. 13.
    Thille AW, Roche-Campo F, Brochard L (2015) Ten reasons to be more attentive to patients when setting the ventilator. Intensive Care Med. doi: 10.1007/s00134-015-3802-5 Google Scholar
  14. 14.
    Blanch L, Villagra A, Sales B, Montanya J, Lucangelo U, Luján M, García-Esquirol O, Chacón E, Estruga A, Oliva JC, Hernández-Abadia A, Albaiceta GM, Fernández-Mondejar E, Fernández R, Lopez-Aguilar J, Villar J, Murias G, Kacmarek RM (2015) Asynchronies during mechanical ventilation are associated with mortality. Intensive Care Med 41:633–641CrossRefPubMedGoogle Scholar
  15. 15.
    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
  16. 16.
    Greenough A, Morley CJ, Pool J (1986) Fighting the ventilator—are fast rates an effective alternative to paralysis? Early Hum Dev 13:189–194CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2015

Authors and Affiliations

  • Gastón Murias
    • 1
  • Candelaria de Haro
    • 2
    • 3
  • Lluis Blanch
    • 2
    • 3
    • 4
    • 5
    Email author
  1. 1.Clínica Bazterrica y Clínica Santa IsabelBuenos AiresArgentina
  2. 2.Critical Care Center, Hospital de SabadellCorporació Sanitaria Universitària Parc TaulíSabadellSpain
  3. 3.Institut de Investigació i Innovació Parc TaulíUniversitat Autònoma de BarcelonaSabadellSpain
  4. 4.CIBER Enfermedades Respiratorias, ISCIIIMadridSpain
  5. 5.Fundació Parc TaulíCorporació Sanitaria Universitària Parc TaulíSabadellSpain

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