New modes of mechanical ventilation: Proportional assist ventilation, neurally adjusted ventilatory assist, and fractal ventilation

Current Opinion in Critical Care

Volumn 9, Issue 1, 2003, Pages 51-58

  Navalesi, Paolo ^a   Costa, Roberta ^b  

^a IRCCS   (Italy)

^b CATHOLIC UNIVERSITY   (Italy)

Author keywords

Alveolar recruitment; Breath to breath variability; Mechanical ventilation; Neuromechanical coupling; Patient ventilator interaction

Indexed keywords

ARTIFICIAL VENTILATION; ASSISTED VENTILATION; BREATHING PATTERN; DIAPHRAGM; FRACTAL VENTILATION; HUMAN; INHALATION; MAN MACHINE INTERACTION; MYOELECTRIC CONTROL; NEURALLY ADJUSTED VENTILATORY ASSIST; OXYGENATION; PROPORTIONAL ASSIST VENTILATION; RESPIRATION CENTER; RESPIRATORY FAILURE; REVIEW; TECHNIQUE;

ALGORITHMS; ANIMALS; DIAPHRAGM; HUMANS; PHRENIC NERVE; RESPIRATION, ARTIFICIAL; RESPIRATORY MECHANICS; RESPIRATORY MUSCLES;

EID: 0037309620     PISSN: 10705295     EISSN: None     Source Type: Journal    
DOI: 10.1097/00075198-200302000-00010     Document Type: Review

References (69)

1. Chatburn RL: Classification of mechanical ventilators. In Principles and Practice of Mechanical Ventilation. Edited by Tobin MJ. New York: McGraw-Hill;1994:37-64.
2. Tobin MJ: Ventilator monitoring, and sharing the data with patients. Am J Respir Crit Care Med 2001, 163:810-811.
3. Tobin MJ: Advances in mechanical ventilation. N Engl J Med 2001, 344:1986-1996.
4. Kilburn KH: Shock, seizures and coma with alkalosis during mechanical ventilation. Ann Intern Med 1966, 65:977-984.
5. Ayres SM, Grace WJ: Inappropriate ventilation and hypoxemia as causes of cardiac arrhythmias. The control of arrhythmias without antiarrhythmic drugs. Am J Med 1969, 46:495-505.
6. Argov Z, Mastaglia FL: Disorders of neuromuscular transmission caused by drugs. N Engl J Med 1979, 301:409-413.
7. Le Bourdelles G, Viires N, Boczkowski J, et al.: Effects of mechanical ventilation on diaphragmatic contractile properties in rats. Am J Respir Crit Care Med 1994, 149:1539-1544.
8. Marini JJ, Capps JS, Culver BH: The inspiratory work of breathing during assisted mechanical ventilation. Chest 1985, 87:612-618.
9. Marini JJ, Rodriguez RM, Lamb V: The inspiratory workload of patient-initiated mechanical ventilation. Am Rev Respir Dis 1986, 134:902-909.
10. Marini JJ, TC Lamb VT: External work output and force generation during synchronized intermittent mandatory ventilation. Am Rev Respir Dis 1966, 136:1169-1179.
11. Maclntyre NR, McConnel R, Cheng KC, et al.: Patient-ventilator flow dyssynchrony: flow-limited versus pressure-limited breaths. Crit Care Med 1997, 25:1671-1677.
12. Remmers JE, Gautier H: Servo respirator constructed from a positive pressure ventilator. J Appl Physiol 1976, 41:252-255.
13. Younes M: Proportional assist ventilation, a new approach to ventilatory support. Am Rev Respir Dis 1992, 145:114-120.
14. Sinderby C, Navalesi P, Beck J, et al.: Neural control of mechanical ventilation in respiratory failure. Nat Med 1999, 5:1433-1436.
15. Navalesi P, Hernandez P, Wongsa A, et al.: Proportional assist ventilation in acute respiratory failure: effects on breathing pattern and inspiratory effort. Am J Respir Crit Care Med 1996, 154:1330-1338.
16. Bigatello LM, Nishimura M, Imanaka H, et al.: Unloading the work of breathing by proportional assist ventilation in a lung model. Crit Care Med 1997, 25:267-262.
17. Appendini L, Purro A, Gudjonsdottir M, et al.: Physiologic response of ventilator-dependent patients with chronic obstructive pulmonary disease to proportional assist ventilation and continuous positive airway pressure. Am J Respir Crit Care Med 1999, 159:1510-1517.
18. Vitacca M, Clini E, Pagani M, et al.: Physiologic effects of early administered mask proportional assist ventilation in patients with chronic obstructive pulmonary disease and acute respiratory failure. Crit Care Med 2000, 28:1791-1797.
19. Wrigge H, Golisch W, Zinserling J, et al.: Proportional assist versus pressure support ventilation: effects on breathing pattern and respiratory work of patients with chronic obstructive pulmonary disease. Intensive Care Med 1999, 25:790-798.
20. Grasso S, Puntillo F, Mascia L, et al.: Compensation for increase in respiratory workload during mechanical ventilation. Am J Respir Crit Care Med 2000, 161:819-826.
21. Giannouli E, Webster K, Roberts D, et al.: Response of ventilator-dependent patients to different levels of pressure support and proportional assist. Am J Respir Crit Care Med 1999, 159:1716-1725.
22. Gay PC, Hess DR, Hill NS: Non-invasive proportional assist ventilation for acute respiratory insufficiency. Am J Respir Crit Care Med 2001, 164:1606-1611. • In this randomized pilot study, PAV is compared with PSV in patients with mild to moderate acute respiratory failure receiving noninvasive ventilation. The results indicate that PAV is feasible and, compared with PSV, is associated with more rapid improvement in a few physiologic variables and is better tolerated by patients. The relatively small sample of patients and the elevated number of secondary outcome measures represent a limitation of this study. More importantly, PAV and PSV were delivered using two different ventilators, only one of which (PAV) incorporated algorithms for air leak compensation.
23. Wysocki M, Richard JC, Meshaka P: Non-invasive proportional assist ventilation compared with non-invasive pressure support ventilation in hypercapnic acute respiratory failure. Crit Care Med 2002, 30:323-329. •• Twelve patients with chronic obstructive pulmonary disease with acute respiratory failure receiving noninvasive ventilatory support underwent two trials with either PAV or PSV. Compared with PSV, PAV was equally effective in unloading the respiratory muscles but improved patient comfort.
24. Grasso S, Ranieri VM: Proportional assist ventilation. Respir Care Clin North Am 2001,7:465-473.
25. Ranieri VM, Grasso S, Mascia L, et al.: Effects of proportional assist ventilationon inspiratory muscle effort in patients with chronic obstructive pulmonary disease and acute respiratory failure. Anesthesiology 1997, 86:79-91.
26. Younes M, Kun J, Masiowski B, et al.: A method for non-invasive determination of inspiratory resistance during proportional assist ventilation. Am J Respir Crit Care Med 2001,163:829-839.
27. Younes M, Webster K, Kun J, et al.: A method for measuring passive elastance during proportional assist ventilation. Am J Respir Crit Care Med 2001, 164:50-60. • A new noninvasive method to continuously assess respiratory system elastance during PAV is presented and evaluated in 74 mechanically ventilated patients.
28. Farre R, Mancini M, Rotger M, et al.: Oscillatory resistance measured during noninvasive proportional assist ventilation. Am J Respir Crit Care Med 2001, 164:790-794. • The authors used the forced oscillation technique to determine patient resistance during noninvasive PAV. The results obtained suggest a possible role of this approach to automatically and continuously update flow assist during PAV.
29. Beck J, Sinderby C, Lindström L, et al.: Effects of lung volume on diaphragm EMG signal strength during voluntary contractions. J Appl Physiol 1998, 65:1123-1134.
30. Laghi F, Topeli A, Tobin MJ: Does resistive loading decrease diaphragmatic contractility before task failure? J Appl Physiol 1998, 8:1103-1112.
31. Aubier M, Murciano D, Lecocguyc Y, et al.: Effect of hypophosphatemia in diaphragmatic contractility in patients with acute respiratory failure. N Engl J Med 1985, 313:420-424.
32. Yanos J, Wood LD, Davis K, et al.: The effect of respiratory and lactic acidosis on diaphragm function. Am Rev Respir Dis 1993, 147:616-619.
33. Nava S, Bellemare F: Cardiovascular failure and apnea in shock. J Appl Physiol 1989, 66:184-189.
34. Younes M: Proportional assist ventilation. In Principles and Practice of Mechanical Ventilation. Edited by Tobin MJ. New York: McGraw-Hill;1994:349-369.
35. Gottfried SB: The role of PEEP or CPAP in the mechanically ventilated COPD patient. In Thorax, edn 2. Edited by Roussos C. New York: Marcel Dekker;1995:2471-2500.
36. Appendini L, Patessio A, Zanaboni S, et al.: Physiologic effects of positive end-expiratory and mask pressure support during exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1994, 149:1069-1076.
37. Lessard MR, Lofaso F, Brochard L: Expiratory muscle activity increases intrinsic positive end-expiratory pressure independently of dynamic hyperinfiation in mechanically ventilated patients. Am J Respir Crit Care Med 1995, 151:562-569.
38. Parthasarathy S, Jubran A, Tobin MJ: Cycling of inspiratory and expiratory muscle groups with the ventilator in airflow limitation. Am J Respir Crit Care Med 1998, 158:1471-1478.
39. Beck J, Sinderby C, Lindström L, et al.: Effects of chest wall configuration on diaphragm interference pattern EMG and compound muscle action potenrials. J Appl Physiol 1997, 82:520-530.
40. Jardin F, Farcot JC, Boissante L, et al.: Influence of positive end-expiratory pressure on left ventricular performance. N Engl J Med 1981,304:387-392.
41. Ranieri VM, Giuliani R, Cinnella G, et al.: Physiologic effect of positive end-expiratory pressure in patients with chronic obstructive pulmonary disease during acute ventilatory failure and controlled mechanical ventilation. Am Rev Respir Dis 1993, 147:5-13.
42. Petrol B, Legare M, Goldberg P, et al.: Continuous positive airway pressure reduces work of breathing and dyspnea during weaning from mechanical ventilation in severe chronic obstructive pulmonary disease. Am Rev Respir Dis 1990, 141:281-288.
43. Du HL, Ohtsuji M, Shigeta M, et al.: Expiratory asynchrony in proportional assist ventilation. Am J Respir Crit Care Med 2002, 165:972-977. •• The authors present a computer simulation aimed at analyzing potential sources of expiratory asynchrony during PAV. They predict a time lag between neural and mechanical inspiration resulting from a system-control delay and related to respiratory time constants and PAV settings.
44. Younes M, Kun J, Webster K, et al.: Response of ventilator-dependent patients to delayed opening of exhalation valve. Am J Respir Crit Care Med 2002, 166:21-30. •• The authors investigate the response to delays in the opening of the exhalation valve in 50 intubated patients receiving mechanical ventilation. They find this response weak on average and not sufficient to counteract the negative effects of extending mechanical inflation into neural expiration. As a result, delayed ventilator cycling off may exacerbate dynamic hyperinfiation and alter patient-ventilator synchrony, thereby promoting the occurrence of ineffective inspiratory efforts.
45. Lourenco RV, Cherniack NS, Maim JR, et al.: Nervous output from the respiratory centers during obstructed breathing. J Appl Physiol 1966, 21:527-533.
46. Beck J, Sinderby C, Weinberg J, et al.: Effects of muscle-to-electrode distance on the human diaphragm electromyogram. J Appl Physiol 1995, 79:975-985.
47. Beck J, Sinderby C, Lindström et al.: Influence of bipolar esophageal electrode positioning on measurements of human crural diaphragm EMG. J Appl Physiol 1996, 81:1434-1449.
48. Sinderby C, Beck J, Lindström L, et al.: Enhancement of signal quality in esophageal recordings of diaphragm EMG. J Appl Physiol 1997, 82:1370-1377.
49. Sinderby C, Beck J, Weinberg J, et al.: Voluntary activation of the human diaphragm in health and disease. J Appl Physiol 1998, 85:2146-2158.
50. Beck J, Gottfried SB, Navalesi P, et al.: Electrical activity of the diaphragm during pressure support ventilation in acute respiratory failure. Am J Resp Crit Care Med 2001, 164:419-424. •• This study shows that the electrical activity of the diaphragm is a valid measurement of the neural drive during pressure support ventilation in acute respiratory failure.
51. Beck J, Spahija J, De Marchie, et al.: Unloading during neurally adjusted ventilatory assist [abstract]. Eur Respir J 2002, 20(suppl):S627.
52. Amato MBP, Barbas SV, Medeiros DM et al.: Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med 1998, 338;347-354.
53. The Acute Respiratory Distress Syndrome Network: Ventilation with lower tidal volumes as compared with the traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000, 342:1301-1308.
54. Hedenstierna G, Tokics L, Strandberg A, et al.: Correlation of gas exchange impairment to the development of atelectasis during anaesthesia and muscle paralysis. Acta Anaesthesiol Scand 1986, 30:183-191.
55. Lefevre GR, Kowalski SE, Girling LG, et al.: Improved arterial oxygenation after oleic acid lung injury in the pig using a computer-controlled mechanical ventilator. Am J Respir Crit Care Med 1996, 154:1567-1572.
56. Pelosi P, Cadringher P, Bottino N, et al.: Sigh in acute respiratory distress syndrome. Am J Respir Crit Care Meal 1999, 159:872-880.
57. Jonson B, Richard J-C, Straus C, et al.: Pressure-volume curves and compliance in acute lung injury: evidence of recruitment above the lower inflection point. Am J Respir Crit Care Med 1999, 159:1172-1178.
58. Hickling KG: The pressure-volume curve is greatly modified by recruitment: a mathematical model of ARDS lungs. Am J Respir Crit Care Med 1998, 158:194-202.
59. Dambrosio M, Roupie E, Moiler JJ, et al.: Effects of positive end-expiratory pressure and different tidal volumes on alveolar recruitment and hyperinfiation. Anesthesiology 1997, 87:495-503.
60. Neumann P, Berglund JE, Mondejar EF, et al.: Effect of different pressure levels on the dynamics of lung collapse and recruitment in oleic-acid-induced lung injury. Am J Respir Crit Care Med 1998, 158:1636-1643.
61. Suki B, Barabasi A, Hantos Z, et al.: Avalanches and power-law behaviour in lung inflation. Nature 1994, 368:615-618.
62. Suki B, Alencar AM, Sujeer MK, et al.: Life-support system benefits from noise. Nature 1998, 393:127-128.
63. Mutch WAC, Eschun GM, Kowalski SE, et al.: Biologically variable ventilation prevents deterioration of gas exchange during prolonged anesthaesia. Br J Anaesth 2000, 84:197-203.
64. Mutch WAC, Harms S, Graham MR, et al.: Biologically variable or naturally noisy mechanical ventilation recruits atelectatic lung. Am J Respir Crit Care Med 2000, 162:319-323.
65. Mutch WAC, Harms S, Lefevre GR, et al.: Biologically variable ventilation increases arterial oxygenation over that seen with positive end-expiratory pressure alone in a porcine model of acute respiratory distress syndrome. Crit Care Med 2000, 28:2457-2464.
66. Boker A, Graham MR, Walley KR, et al.: Improved arterial oxygenation with biologically variable or fractal ventilation using low tidal volumes in a porcine model of acute respiratory distress syndrome. Am J Respir Crit Care Med 2002, 165:456-462. •• In this animal study, BVV improved oxygenation and decreased the concentration of cytokines in the tracheal aspirate compared with volume-targeted, controlled mechanical ventilation delivered according to the ARDS Network protocol.
67. Patroniti N, Foti G, Cortinovis B, et al.: Sigh improves gas exchange and lung volume in patients with acute respiratory syndrome undergoing pressure support ventilation. Anesthesiology 2002, 96:788-794. •• The addition of periodic hyperinflations lasting 3 to 5 seconds (sighs) improved gas exchange, end-expiratory lung volume, and respiratory system compliance in patients with ARDS receiving PSV.
68. Nam AJ, Brower RG, Fessler HE, et al.: Biologic variability in mechanical ventilation rate and tidal volume does not improve oxygenation or lung mechanics in canine oleic acid lung injury. Am J Respir Crit Care Med 2000, 161:1797-1804.
69. Arold SP, Mora R, Lutchen KR, et al.: Variable tidal volume ventilation improves lung mechanics and gas exchange in a rodent model of acute lung injury. Am J Respir Crit Care Med 2002, 165:366-371. •• This study shows that the positive effects of fractal ventilation depend on the amount of incorporated variability, with the best results being obtained at 40% and 60% of the mean tidal volume values.