Understanding spontaneous vs. ventilator breaths: impact and monitoring
Introduction
Spontaneous breathing during mechanical ventilation balances important advantages including improved oxygenation [1] and less diaphragm disuse [2] against serious disadvantages including increased injury to the lung and diaphragm [2, 3, 4, 5] and potentially lower survival [6]. Of course, spontaneous breathing is an absolute requirement for successful weaning, and so it must ultimately be a goal in all patients. While the traditional focus in acute respiratory distress syndrome (ARDS) is on controlling and monitoring ventilator breaths, recent advances point to important differences between spontaneous and mechanical breaths in terms of pathophysiology and monitoring [3, 4, 7]. This paper reviews these insights and provides suggestions for bedside monitoring of spontaneous effort in patients with ARDS during mechanical ventilation, focusing on the use of esophageal manometry.
Monitoring mechanical breaths
During a mechanical breath (i.e., without spontaneous effort),...
Notes
Compliance with ethical standards
Conflicts of interest
TY and BPK have applied for a patent on a CNAP (continuous negative abdominal pressure) device.
Supplementary material
References
- 1.Putensen C, Zech S, Wrigge H, Zinserling J, Stuber F, Von Spiegel T, Mutz N (2001) Long-term effects of spontaneous breathing during ventilatory support in patients with acute lung injury. Am J Respir Crit Care Med 164:43–49CrossRefPubMedGoogle Scholar
- 2.Goligher EC, Dres M, Fan E, Rubenfeld GD, Scales DC, Herridge MS, Vorona S, Sklar MC, Rittayamai N, Lanys A, Murray A, Brace D, Urrea C, Reid WD, Tomlinson G, Slutsky AS, Kavanagh BP, Brochard LJ, Ferguson ND (2018) Mechanical ventilation-induced diaphragm atrophy strongly impacts clinical outcomes. Am J Respir Crit Care Med 197:204–213CrossRefGoogle Scholar
- 3.Yoshida T, Nakahashi S, Nakamura MAM, Koyama Y, Roldan R, Torsani V, De Santis RR, Gomes S, Uchiyama A, Amato MBP, Kavanagh BP, Fujino Y (2017) Volume-controlled ventilation does not prevent injurious inflation during spontaneous effort. Am J Respir Crit Care Med 196:590–601CrossRefPubMedGoogle Scholar
- 4.Morais CCA, Koyama Y, Yoshida T, Plens GM, Gomes S, Lima C, Ramos OP, Pereira SM, Kawaguchi N, Yamamoto H, Uchiyama A, Borges JB, Vidal Melo MF, Tucci MR, Amato MBP, Kavanagh BP, Costa ELV, Fujino Y (2018) High positive end-expiratory pressure renders spontaneous effort non-injurious. Am J Resp Crit Care Med. https://doi.org/10.1164/rccm.201706-1244OC CrossRefPubMedGoogle Scholar
- 5.Magalhaes PAF, Padilha GA, Moraes L, Santos CL, Maia LA, Braga CL, Duarte M, Andrade LB, Schanaider A, Capellozzi VL, Huhle R, Gama de Abreu M, Pelosi P, Rocco PRM, Silva PL (2018) Effects of pressure support ventilation on ventilator-induced lung injury in mild acute respiratory distress syndrome depend on level of positive end-expiratory pressure: a randomised animal study. Eur J Anaesthesiol 35:298–306CrossRefGoogle Scholar
- 6.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 363:1107–1116CrossRefPubMedPubMedCentralGoogle Scholar
- 7.Mauri T, Yoshida T, Bellani G, Goligher EC, Carteaux G, Rittayamai N, Mojoli F, Chiumello D, Piquilloud L, Grasso S, Jubran A, Laghi F, Magder S, Pesenti A, Loring S, Gattinoni L, Talmor D, Blanch L, Amato M, Chen L, Brochard L, Mancebo J (2016) Esophageal and transpulmonary pressure in the clinical setting: meaning, usefulness and perspectives. Intensive Care Med 42:1360–1373CrossRefPubMedGoogle Scholar
- 8.Tsuchida S, Engelberts D, Peltekova V, Hopkins N, Frndova H, Babyn P, McKerlie C, Post M, McLoughlin P, Kavanagh BP (2006) Atelectasis causes alveolar injury in nonatelectatic lung regions. Am J Respir Crit Care Med 174:279–289CrossRefPubMedPubMedCentralGoogle Scholar
- 9.Bellani G, Guerra L, Musch G, Zanella A, Patroniti N, Mauri T, Messa C, Pesenti A (2011) Lung regional metabolic activity and gas volume changes induced by tidal ventilation in patients with acute lung injury. Am J Respir Crit Care Med 183:1193–1199CrossRefPubMedPubMedCentralGoogle Scholar
- 10.Borges JB, Costa EL, Suarez-Sipmann F, Widstrom C, Larsson A, Amato M, Hedenstierna G (2014) Early inflammation mainly affects normally and poorly aerated lung in experimental ventilator-induced lung injury. Crit Care Med 42:e279–e287CrossRefPubMedGoogle Scholar
- 11.Henderson WR, Chen L, Amato MB, Brochard LJ (2017) Fifty years of research in ARDS. Respiratory mechanics in acute respiratory distress syndrome. Am J Resp Crit Care Med 196:822–833CrossRefPubMedGoogle Scholar
- 12.Bellani G, Grasselli G, Teggia-Droghi M, Mauri T, Coppadoro A, Brochard L, Pesenti A (2016) Do spontaneous and mechanical breathing have similar effects on average transpulmonary and alveolar pressure? A clinical crossover study. Crit Care 20:142CrossRefPubMedPubMedCentralGoogle Scholar
- 13.Yoshida T, Fujino Y, Amato MB, Kavanagh BP (2017) Fifty years of research in ARDS. Spontaneous breathing during mechanical ventilation. Risks, mechanisms, and management. Am J Respir Crit Care Med 195:985–992CrossRefPubMedGoogle Scholar
- 14.Yoshida T, Torsani V, Gomes S, De Santis RR, Beraldo MA, Costa EL, Tucci MR, Zin WA, Kavanagh BP, Amato MB (2013) Spontaneous effort causes occult pendelluft during mechanical ventilation. Am J Respir Crit Care Med 188:1420–1427CrossRefPubMedGoogle Scholar
- 15.Guldner A, Pelosi P, Gama de Abreu M (2014) Spontaneous breathing in mild and moderate versus severe acute respiratory distress syndrome. Curr Opin Crit Care 20:69–76CrossRefPubMedGoogle Scholar
Copyright information
© Springer-Verlag GmbH Germany, part of Springer Nature and ESICM 2018