A 50-year-old obese (BMI 51 kg/m2) woman was intubated on October 25, 2014 for acute respiratory distress syndrome due to septic shock from skin and soft tissues infection of the left leg. Because PaO2/FIO2 was 117 mmHg on PEEP, 13 cm H2O and FIO2 0.60, she was placed in the prone position for 16 h under continuous i.v. sedation and neuromuscular blockade. As oxygenation improved, prone positioning was not resumed and neuromuscular blockade and sedation were stopped on October 27 and 28, respectively. On October 31, while Ramsay score was 6, she exhibited a respiratory pattern suggesting patient–ventilator asynchrony. Arterial pH was 7.40 and PaCO2 43 mmHg. As an oesophageal balloon was in place since her admission to monitor esophageal pressure (Pes), airflow, Pes, and airway pressure were recorded (Fig. 1). Deflections of Pes systematically occurred after each mechanical breath, defining a typical pattern of reverse triggering. Only the third breath was not followed by Pes deflection. The peak-to-peak Pes rate was the same (24 cycles per minute) as the breathing frequency set at the ventilator. Accordingly, we did not resume sedation and just waited. Her breathing pattern remained the same for 24 h, then inspiratory efforts re-appeared allowing weaning that succeeded on November 11, 2014. She was discharged alive from the ICU on December 2, 2014. The clear implication of this case is that should Pes be not recorded sedation would have resumed.
Conflicts of interest
On behalf of all authors, the corresponding author states that there is no conflict of interest.
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Yonis, H., Gobert, F., Tapponnier, R. et al. Reverse triggering in a patient with ARDS. Intensive Care Med 41, 1711–1712 (2015). https://doi.org/10.1007/s00134-015-3702-8
- Septic Shock
- Respiratory Distress Syndrome
- Prone Position
- Acute Respiratory Distress Syndrome
- Neuromuscular Blockade