وصف
Ventilator patient asynchrony occurs when there is a mismatch between the patient’s respiratory efforts and the ventilator’s delivered breaths. Common types include trigger asynchrony, flow asynchrony, and cycle asynchrony. Causes may include improper ventilator settings, altered respiratory mechanics, or patient conditions like agitation or airway obstruction.Diagnosis involves clinical observation and ventilator waveform analysis. Management focuses on optimizing ventilator settings, such as adjusting trigger sensitivity, inspiratory flow rates, or cycling thresholds. Sedation or neuromuscular blockade may be considered in severe cases. Regular monitoring and multidisciplinary collaboration are essential to ensure effective ventilation and improve patient outcomes.
ملخص
- Ventilator asynchrony refers to the lack of coordination between a patient's respiratory efforts and the ventilator's support, often due to mismatches in timing or support magnitude. This is a common issue, affecting around 24% of mechanically ventilated patients and is a frequent reason for doctors to simply paralyze or sedate the patient. Asynchrony can lead to diaphragmatic dysfunction, dyspnea, sleep disruption, agitation, delirium, and prolonged healing, and is tied to longer mechanical ventilation durations, higher mortality rates, and weaning failures.
- The asynchrony index, calculated by dividing the number of asynchrony events by the total respiratory rate, should ideally be kept below 10% to avoid adverse outcomes. It's critical to understand the basic concept of synchronized breathing involving three phases: the trigger, limit/control, and cycle, and ensuring a match between the patient's ventilatory drive, need, and inspiratory time with these ventilator phases. It's crucial to accurately assess asynchronous threats as they can potentially harm patients.
- Types of asynchronies are categorized by the ventilator cycle phase, including trigger, flow, and cycling desynchronies. Trigger desynchrony can involve ineffective triggering, trigger delay, auto-triggering, double-triggering, reverse triggering, or premature cycling. These are all related to issues between the patient's respiratory drive and the initiation of the breath.
- Ineffective triggering occurs when the patient attempts to initiate a breath, but the ventilator doesn't respond appropriately, which can arise from overly high trigger sensitivity settings, dynamic hyperinflation, high sedation levels, or weakened diaphragmatic strength. Trigger delay is a milder form, often caused by sensor placement, interface issues, or obstructions. Auto-triggering involves the ventilator initiating breaths without patient effort, commonly due to overly sensitive trigger settings, air leaks, or cardiac oscillations.
- Double triggering, a form of early cycling or cycling asynchrony, involves two continuous breaths initiated by the patient. This is usually because the ventilator is set to deliver a lower flow rate or tidal volume compared to the patient's requirement and can be remedied by increasing the same. The reverse is also possible where the breath is initiated by the ventilator and then followed by the patient and can result in double triggering as well.
- Flow asynchronies, including inadequate flow and flow overshoot, can be identified by looking at pressure waveforms and are more common in volume control ventilation where the flow is fixed. Addressing flow issues requires adjusting ventilator settings to match the patient's demands while cycling desynchrony is classified as either premature, where the patient is still demanding support but the ventilator cycles to expiration, or delayed, where the machine cycle goes into expiration later than the patient.
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