Scientific Letter
Trigger reverse identification in critical care setting
Identificación del trigger inverso en UCI
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array:24 [ "pii" => "S2173572718300936" "issn" => "21735727" "doi" => "10.1016/j.medine.2018.05.003" "estado" => "S300" "fechaPublicacion" => "2018-08-01" "aid" => "1064" "copyright" => "Elsevier España, S.L.U. and SEMICYUC" "copyrightAnyo" => "2017" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Med Intensiva. 2018;42:391-3" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1160 "formatos" => array:3 [ "EPUB" => 168 "HTML" => 523 "PDF" => 469 ] ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0210569117301456" "issn" => "02105691" "doi" => "10.1016/j.medin.2017.04.002" "estado" => "S300" "fechaPublicacion" => "2018-08-01" "aid" => "1064" "copyright" => "Elsevier España, S.L.U. y SEMICYUC" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Med Intensiva. 2018;42:391-3" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 11949 "formatos" => array:3 [ "EPUB" => 191 "HTML" => 7393 "PDF" => 4365 ] ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta científica</span>" "titulo" => "Identificación del <span class="elsevierStyleItalic">trigger</span> inverso en UCI" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "391" "paginaFinal" => "393" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Trigger reverse identification in critical care setting" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1706 "Ancho" => 2500 "Tamanyo" => 251454 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Registro de presión en la vía aérea, presión esofágica, flujo y volumen, en ventilación asistida controlada por volumen en 2 pacientes (izquierda y derecha).</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Presión en la vía aérea</span> el inicio de la inspiración es pasivo, no hay descenso de la presión que indique esfuerzo respiratorio (←). Durante la fase de pausa inspiratoria la morfología y amplitud cambia de unos ciclos a otros (←).</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Flujo</span> inspiratorio es constante, el flujo espiratorio tiene oscilaciones al inicio de la espiración mecánica, que habitualmente reflejan esfuerzos inspiratorios (←).</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Presión esofágica</span> refleja un aumento de presión intratorácica al inicio de la inspiración mecánica seguido de un descenso posterior, que refleja el esfuerzo del paciente (línea discontinua). La relación entre el ciclo mecánico y el esfuerzo es de 1/1 en un caso y variable en el otro (1/1 en el 90% del registro total, coexistiendo con 1/3 y 1/2). El desfase fue de 60 y 47<span class="elsevierStyleHsp" style=""></span>ms o 21 y 14° (θ<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>Tin-Tim/Ttotm · 360). El tiempo inspiratorio del esfuerzo muscular es de 0,8-0,9<span class="elsevierStyleHsp" style=""></span>s y cuando produce un doble disparo aumenta a 1,4<span class="elsevierStyleHsp" style=""></span>s. La presión de oclusión en los primeros 100<span class="elsevierStyleHsp" style=""></span>ms (P01) fue de 3,9 y 8,2<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O en los ciclos con doble <span class="elsevierStyleItalic">trigger</span> en un caso y 4,5 y 8,5<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O respectivamente en el segundo caso.</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Los parámetros relacionados con el esfuerzo inspiratorio: delta presión esofágica (Δpes) 11<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O, la integral presión tiempo (IPT) 1,6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0,3 y 2,5<span class="elsevierStyleHsp" style=""></span>cmH2O·s, el primer paciente tenía derrame pleural no drenado, por lo que medimos la compliancia de la caja torácica durante la ventilación mecánica controlada (160<span class="elsevierStyleHsp" style=""></span>ml/cmH<span class="elsevierStyleInf">2</span>O) y calculamos el producto presión tiempo<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> (área sombreada), considerando la presión de retroceso elástica de la pared torácica, en este caso la estimación del esfuerzo respiratorio es de 5,6<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O·s (96,2<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O·s/m) y en los esfuerzos con doble <span class="elsevierStyleItalic">trigger</span> de 12,5<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O·s. En el segundo caso: Δpes 16<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O, IPT 2,5<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O·s (54<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O·s/m) y en los ciclos con doble disparo de 17<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O·s (370<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O·s/m).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "F. Ruiz Ferrón, J.M. Serrano Simón" "autores" => array:2 [ 0 => array:2 [ "nombre" => "F." "apellidos" => "Ruiz Ferrón" ] 1 => array:2 [ "nombre" => "J.M." 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"tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "394" "paginaFinal" => "395" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "SMART: ¿está el suero salino en la cuerda floja?" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. González-Castro, M. Ortiz-Lasa, J. Bada Da Silva" "autores" => array:3 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "González-Castro" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Ortiz-Lasa" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Bada Da Silva" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0210569117303674" "doi" => "10.1016/j.medin.2017.12.008" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569117303674?idApp=WMIE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572718300997?idApp=WMIE" "url" => "/21735727/0000004200000006/v1_201807240414/S2173572718300997/v1_201807240414/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S217357271830119X" "issn" => "21735727" "doi" => "10.1016/j.medine.2018.05.013" "estado" => "S300" "fechaPublicacion" => "2018-08-01" "aid" => "1106" "copyright" => "Elsevier España, S.L.U. and SEMICYUC" "documento" => "article" "crossmark" => 1 "subdocumento" => "ssu" "cita" => "Med Intensiva. 2018;42:380-90" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2361 "formatos" => array:3 [ "EPUB" => 157 "HTML" => 1677 "PDF" => 527 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review</span>" "titulo" => "A journey between high altitude hypoxia and critical patient hypoxia: What can it teach us about compression and the management of critical disease?" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "380" "paginaFinal" => "390" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Un viaje entre la hipoxia de la gran altitud y la hipoxia del enfermo crítico: ¿qué puede enseñarnos en la compresión y manejo de las enfermedades críticas?" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1327 "Ancho" => 2288 "Tamanyo" => 166276 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Correlation among altitude, atmospheric oxygen partial pressure (PO<span class="elsevierStyleInf">2</span>), and arterial partial oxygen pressure (PaO<span class="elsevierStyleInf">2</span>).</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">PaO<span class="elsevierStyleInf">2</span>: theoretical arterial oxygen partial pressure in exposure to acute hypoxia (without acclimatization).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.L. Avellanas Chavala" "autores" => array:1 [ 0 => array:2 [ "nombre" => "M.L." "apellidos" => "Avellanas Chavala" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0210569117302309" "doi" => "10.1016/j.medin.2017.08.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569117302309?idApp=WMIE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217357271830119X?idApp=WMIE" "url" => "/21735727/0000004200000006/v1_201807240414/S217357271830119X/v1_201807240414/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific Letter</span>" "titulo" => "Trigger reverse identification in critical care setting" "tieneTextoCompleto" => true "saludo" => "Dear Director," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "391" "paginaFinal" => "393" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "F. Ruiz Ferrón, J.M. Serrano Simón" "autores" => array:2 [ 0 => array:4 [ "nombre" => "F." "apellidos" => "Ruiz Ferrón" "email" => array:1 [ 0 => "fruizferron@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J.M." "apellidos" => "Serrano Simón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Cuidados Intensivos, Complejo Hospitalario de Jaén, Jaén, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Cuidados Intensivos, Hospital Reina Sofía, Córdoba, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Identificación del <span class="elsevierStyleItalic">trigger</span> inverso en UCI" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1565 "Ancho" => 2334 "Tamanyo" => 252634 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Registry of the signals (Pva, Pes, flow, vol) in pressure support from both patients. In the first patient, pressure support is set at 18 and PEEP is set at 5<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O, and by improving the interaction with the ventilator, the effort precedes the mechanical cycle (continuous line) with a respiratory frequency of 22<span class="elsevierStyleHsp" style=""></span>bmp to achieve a tidal volume of 0.450<span class="elsevierStyleHsp" style=""></span>l, with no signs of excessive respiratory effort and delta esophageal pressure (Δpes) values <5<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O. In the second case, pressure support is set at 25 and PEEP set at 6 keeping heart rate at 12<span class="elsevierStyleHsp" style=""></span>bmp and tidal volume at 0.783<span class="elsevierStyleHsp" style=""></span>l. In this second case, the patient's effort follows the beginning of the mechanical cycle and, possibly, the ventilator trigger is the change of pressure (or flow) caused by the heartbeat. The patient's effort (dotted line) reduces the phase of airway plateau pressure originating a new increase of inspiratory flow.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In patients on mechanical ventilation, the ventilator cycle of the respirator can induce inspiratory efforts. This mode of interaction has been called trigger reverse (TR). This is a not very well-known asynchrony but potentially more common than expected, possibly due to difficulties when conducting the bedside monitoring of inspiratory muscle effort.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We hereby present two cases of critically ill patients admitted to the ICU who showed this asynchrony right after the ventilator withdrawal. The reason for admission was pneumonia and severe acute pancreatitis. Volume assist-control ventilation (ACV) due to heart failure and acute respiratory distress syndrome in the adult patient was used. After withdrawing sedation, the patients showed one complex interaction, with inspiratory efforts that did not precede the ventilator cycle (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). We monitored the pressures (airway, esophageal) and the flow, and confirmed that the ventilator cycle induces the inspiratory cycle—an asynchrony known as trigger reverse. The ventilation mode was changed to pressure support ventilation (PSV), thus improving the interaction with the ventilator in one of them (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) and requiring ACV in the second case. This mode of interaction is difficult to identify on the ventilator screen, and it is useful to use ACV with constant flow and inspiratory pause. The beginning of inspiration is usually passive, without initial deflection, but it is hard to say that in the pressure-flow curves no effort triggers the ventilator.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> This makes us think that the effort follows the ventilator cycle not only when the beginning of inspiration seems passive but also when the plateau pressure changes cycles and there are oscillations in the peak of expiratory flow. Based on the programmed respiratory frequency, this sequence alternates between synchronized cycles through which the patient triggers the ventilator, and other cycles with double trigger. In the modes controlled by pressure, the effort that follows the ventilator cycle increases inspiratory flow after the initial peak and when it is intense enough, it reduces the pressure curve based on the capacity of response of the ventilator (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Even though the possible implication of RT in mechanical ventilation was recognized years ago,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> there is little information published on trigger reverse in patients with mechanical ventilation and most data come from anesthetized animal experiments<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> and anesthetized healthy individuals with non-invasive<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> and invasive ventilation.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> Recently it has been described after the retrospective analysis of registries conducted on patients with ARDS, being this type of interaction not taken into consideration during the management of patients.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> It has also been reported in situations of brain death after cardiac arrest<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> and in transplanted patients.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The mechanism responsible is still not clear and it occurs in the absence of central ventilatory drive.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> The Hering–Breuer reflex is important, since its frequency is reduced with vagotomy, yet it is not essential.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Whenever there is synchronization or regularity between the ventilator and the neural cycles we call it «entrainment or specific phase». In the cases presented here the relation between the ventilator-induced respiratory frequency and programmed frequency was the same in one case and variable in the other. This has already been described with different frequencies of stimulation (1:1, 1:2, 1:3), even with variable and irregular frequencies.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Registries of pressures, flows, and volumes similar to ours have already been published in a patient with ARDS.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The clinical implication of RT depends on the degree of mismatch between the ventilator cycle and the muscle effort. If it is significant then it can cause double trigger with increased tidal volume and alveolar distention pressure.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> It has been described as one of the causes of double trigger,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> possibly the second cause of asynchrony with the ventilator.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> In modes controlled by pressure, the muscle effort will be compensated by an increased volume in every cycle of the ventilator. The inspiratory work of breathing increases, in our case it is within the limits considered appropriate in mechanical ventilation,<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">7,8</span></a> but it is a lost effort, without performance and excessive at times as it occurs during double trigger. For the management of this asynchrony it has been suggested to use pressure support and modes controlled by pressure with programmed low frequencies.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The incidence and meaning of RT in critically ill patients on mechanical ventilation is still being studied. We still do not know whether it is due to the adequate management of patients, sedation, ventilator parameters, or an adaptative physiological response to mechanical ventilation.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ruiz Ferrón F, Serrano Simón JM. Identificación del <span class="elsevierStyleItalic">trigger</span> inverso en UCI. Med Intensiva. 2018;42:391–393.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1706 "Ancho" => 2500 "Tamanyo" => 253098 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Registry of airway pressure, esophageal pressure, flow, and volume in volume assist-control ventilation (ACV) in 2 patients (left and right). <span class="elsevierStyleItalic">Airway pressure</span> the beginning of breathing is passive, there is no pressure reduction indicative of breathing effort (←). During the phase of inspiratory pause, morphology and amplitude change from one cycle to the next (←). Inspiratory <span class="elsevierStyleItalic">flow</span> is constant, expiratory flow has oscillations at the beginning of mechanical expiration that usually shows inspiratory efforts (←). <span class="elsevierStyleItalic">Esophageal pressure</span> shows increased intrathoracic pressure at the beginning of mechanical inspiration followed by reduced intrathoracic pressure, all indicative of the patient's effort (dotted line). The ratio between the mechanical cycle and the effort is 1/1 in one case and variable in the other (1/1 in 90% of the total registry, coexisting with 1/3 and 1/2). The mistmatch was 60 and 47<span class="elsevierStyleHsp" style=""></span>ms or 21 and 14° (<span class="elsevierStyleItalic">θ</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>Tin<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span>Tim/Ttotm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>360). Inspiratory time of muscle effort is 0.8–0.9<span class="elsevierStyleHsp" style=""></span>s and when it causes double trigger it goes up to 1.4<span class="elsevierStyleHsp" style=""></span>s. Occlusion pressure during the first 100<span class="elsevierStyleHsp" style=""></span>ms (P01) was 3.9 and 8.2<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O in cycles with double trigger in one case, and 4.5 and 8.5<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O, respectively in the second case. Parameters associated with inspiratory effort: delta esophageal pressure (Δpes) vales of 11<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O, and pressure time integral (PTI) of 1.6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.3 and 2.5<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O<span class="elsevierStyleHsp" style=""></span>s, the first patient showed undrained pleural effusion, which is why we measured the chest wall compliance during controlled mechanical ventilation (160<span class="elsevierStyleHsp" style=""></span>ml/cmH<span class="elsevierStyleInf">2</span>O) and estimated the pressure-time product<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> (darkened area). Considering the chest wall elastic recoil pressure, in this case the estimated respiratory effort is 5.6<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O<span class="elsevierStyleHsp" style=""></span>s (96.2<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O<span class="elsevierStyleHsp" style=""></span>s/m) and double trigger efforts 12.5<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O<span class="elsevierStyleHsp" style=""></span>s. In the second case: Δpes 16<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O, PTI 2.5<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O<span class="elsevierStyleHsp" style=""></span>s (54<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O<span class="elsevierStyleHsp" style=""></span>s/m) and double trigger cycles: 17<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O<span class="elsevierStyleHsp" style=""></span>s (370<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O<span class="elsevierStyleHsp" style=""></span>s/m).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1565 "Ancho" => 2334 "Tamanyo" => 252634 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Registry of the signals (Pva, Pes, flow, vol) in pressure support from both patients. In the first patient, pressure support is set at 18 and PEEP is set at 5<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O, and by improving the interaction with the ventilator, the effort precedes the mechanical cycle (continuous line) with a respiratory frequency of 22<span class="elsevierStyleHsp" style=""></span>bmp to achieve a tidal volume of 0.450<span class="elsevierStyleHsp" style=""></span>l, with no signs of excessive respiratory effort and delta esophageal pressure (Δpes) values <5<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O. In the second case, pressure support is set at 25 and PEEP set at 6 keeping heart rate at 12<span class="elsevierStyleHsp" style=""></span>bmp and tidal volume at 0.783<span class="elsevierStyleHsp" style=""></span>l. In this second case, the patient's effort follows the beginning of the mechanical cycle and, possibly, the ventilator trigger is the change of pressure (or flow) caused by the heartbeat. The patient's effort (dotted line) reduces the phase of airway plateau pressure originating a new increase of inspiratory flow.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Classifying different types of double triggering based on airway pressure and flow deflection in mechanically ventilated patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "L. Kuang-Ming" 1 => "O. Chih-Ying" 2 => "C. Chang-Wen" 3 => "K.M. Liao" 4 => "C.Y. Ou" 5 => "C.W. Chen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4187/respcare.00731" "Revista" => array:6 [ "tituloSerie" => "Respir Care" "fecha" => "2011" "volumen" => "56" "paginaInicial" => "460" "paginaFinal" => "466" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21255492" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0055" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Respiratory phase locking during mechanical ventilation in anesthetized human subjects" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C.L. Graves" 1 => "D. Glass" 2 => "R. Laporta" 3 => "M.A. Grassino" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1152/ajpregu.1986.250.5.R902" "Revista" => array:6 [ "tituloSerie" => "Am J Physiol" "fecha" => "1986" "volumen" => "250" "paginaInicial" => "R902" "paginaFinal" => "R909" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3706575" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0060" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Phase locking of the respiratory rhythm in cats to a mechanical ventilator" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G.A. Petrillo" 1 => "L. Glass" 2 => "T. Trippenbach" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Can J Physiol Pharmacol" "fecha" => "1983" "volumen" => "61" "paginaInicial" => "599" "paginaFinal" => "607" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6576843" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0065" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Vagal feedback in the entrainment of respiration to mechanical in sleeping humans" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "P.M. Simon" 1 => "A.M. Habel" 2 => "J.A. Daubenspeck" 3 => "J.C. Leiter" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1152/jappl.2000.89.2.760" "Revista" => array:6 [ "tituloSerie" => "J Appl Physiol" "fecha" => "2000" "volumen" => "89" "paginaInicial" => "760" "paginaFinal" => "769" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10926663" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0070" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mechanical ventilation-induced reverse-triggered breaths. A frequently unrecognized form of neuromechanical coupling" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E. Akoumianaki" 1 => "A. Lyazidi" 2 => "N. Rey" 3 => "D. Matamis" 4 => "N. Perez-Martinez" 5 => "R. Giraud" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.12-1817" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2013" "volumen" => "143" "paginaInicial" => "927" "paginaFinal" => "938" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23187649" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0075" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Patient-ventilator asynchrony due reverse triggering occurring in brain-dead patients: clinical implications and physiological meaning" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Delisle" 1 => "E. Charbonney" 2 => "M. Albert" 3 => "P. Ouellet" 4 => "P. Marsolais" 5 => "M. Rigollot" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2016" "volumen" => "194" "paginaInicial" => "1167" "paginaFinal" => "1168" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0080" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reverse triggering in a patient with ARDS" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "H. Yonis" 1 => "F. Gobert" 2 => "R. Tapponnier" 3 => "C. Guerin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00134-015-3702-8" "Revista" => array:6 [ "tituloSerie" => "Intensive Care Med" "fecha" => "2015" "volumen" => "41" "paginaInicial" => "1711" "paginaFinal" => "1712" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25731636" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0085" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Advances in mechanical ventilation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M.J. Tobin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJM200106283442606" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2001" "volumen" => "344" "paginaInicial" => "1986" "paginaFinal" => "1996" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11430329" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0090" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Variability of patient ventilator interaction with pressure support ventilation in patients with chronic obstructive pulmonary disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Jubran" 1 => "W.B. van de Graaf" 2 => "M.J. Tobin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/ajrccm.152.1.7599811" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "1995" "volumen" => "152" "paginaInicial" => "129" "paginaFinal" => "136" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7599811" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735727/0000004200000006/v1_201807240414/S2173572718300936/v1_201807240414/en/main.assets" "Apartado" => array:4 [ "identificador" => "15647" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735727/0000004200000006/v1_201807240414/S2173572718300936/v1_201807240414/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572718300936?idApp=WMIE" ]
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