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

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...


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Conflicts of interest

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

Supplementary material

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Supplementary material 1 (DOCX 36 kb)


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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

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