Advertisement

Reverse triggering with breath stacking during mechanical ventilation results in large tidal volumes and transpulmonary pressure swings

  • Henry K. SuEmail author
  • Stephen H. Loring
  • Daniel Talmor
  • Elias Baedorf Kassis
Letter

Dear Editor,

Reverse triggering with breath stacking is a form of dyssynchrony in mechanically ventilated patients with ARDS which may contribute to ventilator-induced lung injury (VILI) through the delivery of large tidal volumes (Vt) [1]. It occurs when an initially passive breath is followed during the expiratory phase by a reflexive or purposeful diaphragmatic contraction of sufficient force to trigger the delivery of an additional breath. Differentiating reverse triggering from other causes of breath stacking (e.g. double triggering) is challenging using standard time tracings. Our group has recently employed the Campbell diagram, which uses esophageal pressure (Pes) to demonstrate the pressure–volume characteristics of the chest wall, to phenotype breathing patterns [2]. This is an ideal tool for identifying the subtle inspiratory differences associated with reverse triggering.

We generated Campbell diagrams in patients with ARDS from a prior study [ 3] to identify reverse...

Notes

Compliance with ethical standards

Conflicts of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Supplementary material

134_2019_5608_MOESM1_ESM.docx (36 kb)
Supplementary material 1 (DOCX 36 kb)

References

  1. 1.
    de Haro C, López-Aguilar J, Magrans R et al (2018) Double cycling during mechanical ventilation: frequency, mechanisms, and physiologic implications. Crit Care Med 46(9):1385–1392CrossRefGoogle Scholar
  2. 2.
    Baedorf Kassis E, Loring SH, Talmor D (2018) Lung volumes and transpulmonary pressure are decreased with expiratory effort and restored with passive breathing in ARDS: a reapplication of the traditional Campbell diagram. Intensive Care Med 44(4):534–536CrossRefGoogle Scholar
  3. 3.
    Talmor D, Sarge T, Malhotra A et al (2008) Mechanical ventilation guided by esophageal pressure in acute lung injury. N Engl J Med 359(20):2095–2104.  https://doi.org/10.1056/NEJMoa0708638 CrossRefGoogle Scholar
  4. 4.
    Pelosi P, Cadringher P, Bottino N et al (1999) Sigh in acute respiratory distress syndrome. Am J Respir Crit Care Med 159(3):872–880.  https://doi.org/10.1164/ajrccm.159.3.9802090 CrossRefGoogle Scholar
  5. 5.
    Pellegrini M, Hedenstierna G, Roneus A, Segelsjö M, Larsson A, Perchiazzi G (2017) The diaphragm acts as a brake during expiration to prevent lung collapse. Am J Respir Crit Care Med 195(12):1608–1616.  https://doi.org/10.1164/rccm.201605-0992OC CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Harvard Medical SchoolBostonUSA
  2. 2.Department of Anesthesia, Critical Care and Pain MedicineBeth Israel Deaconess Medical Center and Harvard Medical SchoolBostonUSA
  3. 3.Division of Pulmonary, Critical Care and Sleep MedicineBeth Israel Deaconess Medical Center and Harvard Medical SchoolBostonUSA

Personalised recommendations