Résumé
La ventilation n’est pas un phénomène monotone; elle est au contraire variable dans le temps, non seulement au gré des ajustements homéostasiques aux besoins de l’organisme, mais aussi d’un cycle à l’autre (périodicité dite « anharmonique »). Cette variabilité cycle-à-cycle du volume courant et de ses composantes est liée à la nature complexe, pseudochaotique — au sens mathématique de ces termes — de la dynamique de la commande respiratoire centrale qui génère le débit ventilatoire. Une certaine variabilité respiratoire est synonyme de « bonne santé » respiratoire, et la diminution de la variabilité du comportement ventilatoire est pathologique. Cette diminution peut traduire soit des modifications centrales, soit le « filtrage » de la variabilité de la commande par des modifications de charge mécanique: la complexité du débit ventilatoire et la variabilité cycle-à-cycle de la ventilation sont liées au couplage neuromécanique respiratoire et à l’équilibre charge-capacité. Ainsi, en réanimation, une faible variabilité ventilatoire prédit l’échec du sevrage la ventilation mécanique. Elle est de plus un facteur indépendant de surmortalité. De plus, dans des modèles animaux, l’adjonction artificielle d’une variabilité extrinsèque améliore la mécanique respiratoire et les échanges gazeux. La restauration de la variabilité ventilatoire naturelle par certains modes d’assistance pourrait ainsi s’avérer bénéfique.
Abstract
Ventilation is not monotonous. In contrast, the breathing pattern components vary with time, not only with respect to homeostatic adjustment needs, but also from one cycle to another (often referred to as the “anharmonic” period). These breath-by-breath variations in tidal volume and its components are a result of the complex and chaotic nature — in mathematical terms — of the central ventilator command that creates the tidal volume. Respiratory variability reflects “healthy’ breathing, whereas decreasing variability of the breathing pattern components is a reflection of “poor health”. This decrease may be due to central command changes or, it may be due to the “filtering” of the central variability changes in regards to the mechanical loads: the complexity of the ventilatory flow and its breath-by-breath variability is related to both the neuro-mechanical coupling and the load-capacity adequacy. Thus, in intensive care, low ventilatory variability predicts mechanical ventilation weaning failure and is also an independent risk factor of death. Moreover, in animal models, the addition of extrinsic variability has shown improvements in both lung mechanics and gas exchange. The restoration of a natural variability through new mechanical ventilation modes may prove beneficial.
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Schmidt, M., Cecchini, J., Kindler, F. et al. Variabilité ventilatoire et assistance ventilatoire en réanimation. Réanimation 23, 17–24 (2014). https://doi.org/10.1007/s13546-014-0843-z
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DOI: https://doi.org/10.1007/s13546-014-0843-z