Reduction of patient-ventilator asynchrony by reducing tidal volume during pressure-support ventilation

Objective: To identify ventilatory setting adjustments that improve patient-ventilator synchrony during pressure-support ventilation in ventilator-dependent patients by reducing ineffective triggering events without decreasing tolerance. Design and setting: Prospective physiological study in a 13-bed medical intensive care unit in a university hospital. Patients and participants: Twelve intubated patients with more than 10% of ineffective breaths while receiving pressure-support ventilation. Interventions: Flow, airway-pressure, esophageal-pressure, and gastric-pressure signals were used to measure patient inspiratory effort. To decrease ineffective triggering the following ventilator setting adjustments were randomly adjusted: pressure support reduction, insufflation time reduction, and change in end-expiratory pressure. Measurements and results: Reducing pressure support from 20.0 cm H2O (IQR 19.5 - 20) to 13.0 (12.0 - 14.0) reduced tidal volume [10.2ml/kg predicted body weight (7.2 - 11.5) to 5.9 (4.9 - 6.7)] and minimized ineffective triggering events [45% of respiratory efforts (36 - 52) to 0% (0 - 7)], completely abolishing ineffective triggering in two-thirds of patients. The ventilator respiratory rate increased due to unmasked wasted efforts, with no changes in patient respiratory rate [26.5 breaths/min (23.1 - 31.9) vs. 29.4 (24.6 - 34.5)], patient effort, or arterial PCO2. Shortening the insufflation time reduced ineffective triggering events and patient effort, while applying positive end-expiratory pressure had no influence on asynchrony. Conclusions: Markedly reducing pressure support or inspiratory duration to reach a tidal volume of about 6 ml/kg predicted body weight eliminated ineffective triggering in two-thirds of patients with weaning difficulties and a high percentage of ineffective efforts without inducing excessive work of breathing or modifying patient respiratory rate.