Author Souvik Chatterjee, MD Department of Critical Care Medicine, Department of Pulmonary Medicine. Medstar Washington Hospital Center.
Case
A 65-year-old female with a history of peripheral arterial disease
(PAD), coronary artery disease (CAD), and s/p CABG 5 years ago presented
with acute right sided weakness and was found to have an ischemic
stroke in the MCA distribution. She was intubated for mechanical
thrombectomy after tPA administration and persistent symptoms.
Post-procedure, she was profoundly hypoxic with 02 saturation of 88% on FiO2 1.0 and PEEP 14 cm H20.
A lung protective ventilation strategy was initiated using Volume
Assist Control ventilation with TV of 6 cc/kg of IBW, PEEP was
up-titrated and inhaled epoprostenol was initiated. The patient was
sedated with dexmedatomidine and PRN fentanyl. Representative ventilator
waveforms are shown below.
Question
The waveforms reveal what potential ventilator associated lung injury risk?
A. Delayed Cycling B. Atelectrauma C. Auto-triggering D. Barotrauma
Answer
Answer: D. Barotrauma
Discussion
This patient was diagnosed with moderate ARDS based on the acute
onset of bilateral infiltrates and respiratory failure not completely
explained by cardiac failure and fluid overload.1 In order to
minimize ventilator associated lung injury (VALI), specifically macro
and micro barotrauma, a low tidal volume strategy of 6 cc/kg of IBW was
instituted based on the landmark ARDSNet study.2 Additionally, with the goals to minimize delirium and promote early mobility, sedation was intentionally minimized.3
The waveform image demonstrates both cycling and triggering
asynchronies, premature cycling and ineffective triggering,
respectively. A premature cycle results when the patient’s neural
inspiratory time is prolonged relative to the ventilator’s set
inspiratory time. Premature cycling can be identified on the first two
breaths of the flow waveform, where at the beginning of expiration there
is a notch or delay in expiratory flow (less expiratory flow then
expected) indicating a continuation of the patient’s inspiratory effort
beyond the ventilator’s preset inspiratory time (red arrow). This
problem results in excessive work of breathing and likely elevated
transpulmonary pressures for the patient as they continue to inspire
against a closed ventilator inspiratory valve. During expiration the
expiratory flow curve has a flattened appearance indicating active
exhalation until the next inspiration begins, which also adds to the
patient’s work of breathing.
The 3rd through 5th breaths (red circle)
demonstrate what is colloquially known as “breath stacking” but more
accurately can be described as a severe premature cycling. The patient’s
prolonged inspiratory effort relative to the machine’s set inspiratory
time repeatedly triggers the ventilator, resulting in consecutive
delivery of the preset Vt. In this case, the patient receives the
prescribed 400 cc (6cc/kg IBW), three times sequentially resulting in an
inhaled tidal volume of 1200cc or 18cc/kg IBW. A tidal volume of 1.2 L
poses significant risk of barotrauma and volutrauma and is in direct
opposition with the consensus recommendations for ARDS.4
Additionally, on the final breath of the scalar, there is a trigger
asynchrony, specifically an ineffective trigger (yellow arrow), that is
most likely due to an increase in end-expiratory volume and pressure
following the delivery of three successive mandatory-volume breaths.
Triggering and cycling asynchronies increase the patient’s work of
breathing and increase the risk of barotrauma.5,6
For these reasons, the ventilator’s inspiratory time was increased
(by decreasing the peak inspiratory flow rate and increasing the tidal
volume to 8cc/kg IBW). However, these adjustments alone failed to
resolve the premature cycling, so the patient was also started on a
continuous propofol infusion and was paralyzed with intermittent
vecuronium, resulting in improvement in PaO2 by 50 mm Hg. The
PEEP was subsequently titrated down, and the patient was liberated from
mechanical ventilation within 48 hours.
References
The ARDS Definition Task Force. Acute Respiratory Distress Syndrome: The Berlin Definition. JAMA 2012; 307(23): 2526–33.
The Acute Respiratory Distress Syndrome Network. Ventilation with
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Vasilevskis E, Ely E, Speroff T, et al. Reducing iatrogenic risks:
ICU-acquired delirium and weakness-crossing the quality chasm. Chest
2010; 138(5): 1224-33.
Fan E, Del Sorbo L, Goligher E, et al. An official American Thoracic
Society/European Society of Intensive Care Medicine/Society of Critical
Care Medicine clinical practice guideline: mechanical ventilation in
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Crit Care Med 2017; 195(9): 1253-63.
Epstein S. How often does patient-ventilator asynchrony occur and what are the consequences. Respir Care 2011; 56(1): 25–35.
Mauri T, Cambiaghi B, Spinelli E, et al. Spontaneous breathing: a
double-edged sword to handle with care. Ann Transl Med 2017; 5(14): 292.