Optimizing Patient-Ventilator Synchrony

Scott K. Epstein

doi:10.1055/s-2001-13828

Seminars in Respiratory and Critical Care Medicine, Inhaltsverzeichnis

Semin Respir Crit Care Med 2001; 22(2): 137-152
DOI: 10.1055/s-2001-13828

Optimizing Patient-Ventilator Synchrony

Scott K. Epstein

Pulmonary and Critical Care Division, New England Medical Center, Boston, Massachusetts

Abstract

ABSTRACT

Mechanical ventilation assumes the work of breathing, improves gas exchange, and unloads the respiratory muscles, all of which require good synchronization between the patient and the ventilator. Causes for patient-ventilator dyssynchrony include both patient factors (abnormalities of respiratory drive and abnormal respiratory mechanics) and ventilator factors (triggering, flow delivery, breath termination criteria, the level and mode of ventilator support, and imposed work of breathing). Although patient-ventilator dyssynchrony can often be detected on physical exam, careful analysis of ventilator waveforms (pressure-time, flow-time) allows for more precise definition of the underlying cause. Patient-ventilator interaction can be improved by reversing patient factors that alter respiratory drive or elevate patient ventilatory requirements and by correcting factors that contribute to dynamic hyperinflation. Proper setting of the ventilator using sensitive triggering mechanisms, satisfactory flow rates, adequate delivered minute ventilation, matching machine T_I to neural TI, and applying modes that overcome the imposed work of breathing, further optimize patient-ventilator synchrony.

Volltext

Referenzen

REFERENCES

1 Brochard L, Rauss A, Benito S, Conti G, Mancebo J, Rekik N. Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation. Am J Respir Crit Care Med . 1994; 150 896-903
2 Ely E W, Baker A M, Dunagan D P, Burke H L, Smith A C, Kelly P T. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med . 1996; 335 1864-1869
3 Epstein S K. Weaning Parameters. Respir Care Clin N Am . 2000; 6 253-301
4 Esteban A, Frutos F, Tobin M J, Alia I, Solsona J F, Valverdu I. A comparison of four methods of weaning patients from mechanical ventilation. N Engl J Med . 1995; 332 345-350
5 Dick C, Sassoon C. Patient-ventilator interactions. Clin Chest Med . 1996; 17 423-438
6 Burton S, Hubmayr R. Determination of patient-ventilator interactions: bedside waveform analysis. In: Tobin M, ed. Principles and Practice of Mechanical Ventilation New York: McGraw-Hill, 1994: 655-666
7 Tobin M, Fahey P. Management of the patient who is ``fighting the ventilator''. In: Tobin M, ed. Principles and Practice of Mechanical Ventilation New York: McGraw-Hill, 1994: 1149-1162
8 MacIntyre N R, McConnell R, Cheng K C, Sane A. Patient-ventilator flow dyssynchrony: flow-limited versus pressure-limited breaths. Crit Care Med . 1997; 25 1671-1677
9 Nava S, Bruschi C, Fracchia C, Braschi A, Rubini F. Patient-ventilator interaction and inspiratory effort during pressure support ventilation in patients with different pathologies. Eur Respir J . 1997; 10 177-183
10 Fabry B, Haberthur C, Zappe D, Guttmann J, Kuhlen R, Stocker R. Breathing pattern and additional work of breathing in spontaneously breathing patients with different ventilatory demands during inspiratory pressure support and automatic tube compensation. Intensive Care Med . 1997; 23 545-552
11 Chao D C, Scheinhorn D J, Stearn-Hassenpflug M. Patient-ventilator trigger asynchrony in prolonged mechanical ventilation. Chest . 1997; 112 1592-1599
12 Kollef M H, Levy N T, Ahrens T S, Schaiff R, Prentice D, Sherman G. The use of continuous iv sedation is associated with prolongation of mechanical ventilation. Chest . 1998; 114 541-548
13 Kress J P, Pohlman A S, O'Connor M F, Hall J B. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med . 2000; 342 471-1477
14 Murciano D, Boczkowski J, Lecocguic Y, Milic-Emili J, Patiente R, Aubier M. Tracheal occlusion pressure: a simple index to monitor respiratory muscle fatigue during acute respiratory failure in patients with chronic obstructive pulmonary disease. Ann Intern Med . 1988; 108 800-805
15 Sassoon C SH, Te T T, Mahutte C K, Light R W. Airway occlusion pressure: an important indicator for successful weaning in patients with chronic obstructive pulmonary disease. Am Rev Respir Dis . 1987; 135 107-113
16 Sassoon C S, Mahutte C K. Airway occlusion pressure and breathing pattern as predictors of weaning outcome. Am Rev Respir Dis . 1993; 148 860-866
17 Pesenti A, Rossi N, Calori A, Foti G, Rossi G P. Effects of short-term oxygenation changes on acute lung injury patients undergoing pressure support ventilation. Chest . 1993; 103 1185-1189
18 Epstein S, Singh N. Respiratory acidosis. Respir Care . 2001; 46 366-383
19 Hubmayr R D. The importance of patient/ventilator interactions during noninvasive mechanical ventilation. Acta Anaesthesiol Scand Suppl . 1996; 109 46-47
20 Del Rosario N, Sassoon C S, Chetty K G, Gruer S E, Mahutte C K. Breathing pattern during acute respiratory failure and recovery. Eur Respir J . 1997; 10 2560-2565
21 Marini J J, Rodriguez R M, Lamb V. The inspiratory workload of patient-initiated mechanical ventilation. Am Rev Respir Dis . 1986; 134 902-909
22 Sassoon C SH, Del Rosario N, Fei R, Rheeman C H, Gruer S E, Mahutte C K. Influence of pressure- and flow-triggered synchronous intermittent mandatory ventilation on inspiratory muscle work. Crit Care Med . 1994; 22 1933-1941
23 Pepe P E, Marini J J. Occult positive end-expiratory pressure in mechanically ventilated patients with airflow obstruction: the auto-PEEP effect. Am Rev Respir Dis . 1982; 126 166-170
24 Ranieri V M, Grasso S, Fiore T, Giuliani R. Auto-positive end-expiratory pressure and dynamic hyperinflation. Clin Chest Med . 1996; 17 379-394
25 Rossi A, Gottfried S B, Higgs B D, Zocchi L, Grassino A, Milic-Emili J. Respiratory mechanics in mechanically ventilated patients with respiratory failure. J Appl Physiol . 1985; 58 1849-1858
26 Rossi A, Gottfried S B, Zocchi L, Higgs B D, Lennox S, Calverley P M. Measurement of static compliance of the total respiratory system in patients with acute respiratory failure during mechanical ventilation: the effect of intrinsic positive end-expiratory pressure. Am Rev Respir Dis . 1985; 131 672-677
27 Brandolese R, Broseghini C, Polese G, Bernasconi M, Brandi G, Milic-Emili J. Effects of intrinsic PEEP on pulmonary gas exchange in mechanically-ventilated patients. Eur Respir J . 1993; 6 358-363
28 Jubran A, Tobin M J. Pathophysiologic basis of acute respiratory distress in patients who fail a trial of weaning from mechanical ventilation. Am J Respir Crit Care Med . 1997; 155 906-915
29 Coussa M L, Guerin C, Eissa N T, Corbeil C, Chasse M, Braidy J. Partitioning of work of breathing in mechanically ventilated COPD patients. J Appl Physiol . 1993; 75 1711-1719
30 Fleury B, Murciano D, Talamo C, Aubier M, Pariente R, Milic-Emili J. Work of breathing in patients with chronic obstructive pulmonary disease in acute respiratory failure. Am Rev Respir Dis . 1985; 131 822-827
31 Epstein S K. An overview of respiratory muscle function. Clin Chest Med . 1994; 15 619-639
32 Ninane V, Rypens F, Yernault J-C, DeTroyer A. Abdominal muscle use during breathing in patients wigh chronic airflow obstruction. Am Rev Respir Dis . 1992; 146 16-21
33 Ninane V, Yernault J C, de Troyer A. Intrinsic PEEP in patients with chronic obstructive pulmonary disease: role of expiratory muscles. Am Rev Respir Dis . 1993; 148 1037-1042
34 Tobert D G, Simon P M, Stroetz R W, Hubmayr R D. The determinants of respiratory rate during mechanical ventilation. Am J Respir Crit Care Med . 1997; 155 485-492
35 Iber C, Simon P, Skatrud J B, Mahowald M W, Dempsey J A. The Breuer-Hering reflex in humans: effects of pulmonary denervation and hypocapnia. Am J Respir Crit Care Med . 1995; 152 217-224
36 Dempsey J A, Skatrud J B. A sleep-induced apneic threshold and its consequences. Am Rev Respir Dis . 1986; 133 1163-1170
37 Leung P, Jubran A, Tobin M J. Comparison of assisted ventilator modes on triggering, patient effort, and dyspnea. Am J Respir Crit Care Med . 1997; 155 1940-1948
38 Imanaka H, Nishimura M, Takeuchi M, Kimball W R, Yahagi N, Kumon K. Autotriggering caused by cardiogenic oscillation during flow-triggered mechanical ventilation. Crit Care Med . 2000; 28 402-407
39 Aslanian P, El Atrous S, Isabey D, Valente E, Corsi D, Harf A. Effects of flow triggering on breathing effort during partial ventilatory support. Am J Respir Crit Care Med . 1998; 157 135-143
40 Goulet R, Hess D, Kacmarek R M. Pressure vs flow triggering during pressure support ventilation. Chest . 1997; 111 1649-1653
41 Sassoon C. Mechanical ventilator design and function: the trigger variable. Respir Care . 1992; 37 1056-1069
42 Sassoon S CH, Mahutte C K, Te T T, Simmons C H, Light R W. Work of breathing and airway occlusion pressure during assist-mode mechanical ventilation. Chest . 1988; 93 571-576
43 Ward M E, Corbeil C, Gibbons W, Newman S, Macklem P T. Optimization of respiratory muscle relaxation during mechanical ventilation. Anesthesiology . 1988; 69 29-35
44 Manning H L, Molinary E J, Leiter J C. Effect of inspiratory flow rate on respiratory sensation and pattern of breathing. Am J Respir Crit Care Med . 1995; 151 751-757
45 MacIntyre N R, Ho L I. Effects of initial flow rate and breath termination criteria on pressure support ventilation. Chest . 1991; 99 134-138
46 Jubran A, Van de Graaff B W, Tobin M J. Variability of patient-ventilator interaction with pressure support ventilation in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med . 1995; 152 129-136
47 Puddy A, Younes M. Effect of inspiratory flow rate on respiratory output in normal subjects. Am Rev Respir Dis . 1992; 146 787-789
48 Hubmayr R D, Abel M D, Rehder K. Physiologic approach to mechanical ventilation. Crit Care Med . 1990; 18 103-113
49 Fabry B, Guttmann J, Eberhard L, Bauer T, Haberthur C, Wolff G. An analysis of desynchronization between the spontaneously breathing patient and ventilator during inspiratory pressure support. Chest . 1995; 107 1387-1394
50 Parthasarathy S, Jubran A, Tobin M J. Cycling of inspiratory and expiratory muscle groups with the ventilator in airflow limitation. Am J Respir Crit Care Med . 1998; 158 1471-1478
51 Manning H L, Shea S A, Schwartzstein R M, Lansing R W, Brown R, Banzett R B. Reduced tidal volume increases ``air hunger'' at fixed PCO₂ in ventilated quadriplegics. Respir Physiol . 1992; 90 19-30
52 Ayres S, Kozam R, Lukes D. The effect of intermittent positive pressure breathing on the intrathoracic pressure, pulmonary mechanics and work of breathing. Am Rev Respir Dis . 1963; 87 370-379
53 Marini J J, Smith T C, Lamb V J. External work output and force generation during synchronized intermittent mechanical ventilation: effect of machine assistance on breathing effort. Am Rev Respir Dis . 1988; 138 1169-1179
54 Flick G R, Bellamy P E, Simmons D H. Diaphragmatic contraction during assisted mechanical ventilation. Chest . 1989; 96 130-135
55 Imsand C, Feihl F, Perret C, Fitting J W. Regulation of inspiratory neuromuscular output during synchronized intermittent mechanical ventilation. Anesthesiology . 1994; 80 13-22
56 Bersten A D, Rutten A J, Vedig A E, Skowronski G A. Additional work of breathing imposed by endotracheal tubes, breathing circuits, and intensive care ventilators. Crit Care Med . 1989; 17 671-677
57 Bolder P M, Healy T E, Bolder A R, Beatty P C, Kay B. The extra work of breathing through adult endotracheal tubes. Anesth Analg . 1986; 65 853-859
58 Brochard L, Rua F, Lorino H. Inspiratory pressure support compensates for the additional work of breathing caused by the endotracheal tube. Anesthesiology . 1991; 75 739-745
59 Marini J J, Capps J S, Culver B H. The inspiratory work of breathing during assisted mechanical ventilation. Chest . 1985; 87 612-618
60 Shapiro M, Wilson R K, Casar G, Bloom K, Teague R B. Work of breathing through different sized endotracheal tubes. Crit Care Med . 1986; 14 1028-1031
61 Conti G, Rocco M, De Blasi A R, Lappa A, Antonelli M, Bufi M. A new device to remove obstruction from endotracheal tubes during mechanical ventilation in critically ill patients. Intensive Care Med . 1994; 20 573-576
62 Wright P E, Marini J J, Bernard G R. In vitro versus in vivo comparison of endotracheal tube airflow resistance. Am Rev Respir Dis . 1989; 140 10-16
63 DeHaven C B, Kirton O C, Morgan J P, Hart A ML, Shatz D V, Civetta J M. Breathing measurement reduces fals-negative classification of tachypneic preextubation trial failures. Crit Care Med . 1996; 24 976-980
64 Kirton O C, DeHaven C B, Morgan J P, Windsor J, Civetta J M. Elevated imposed work of breathing masquerading as ventilator weaning intolerance. Chest . 1995; 108 1021-1025
65 Banner M J, Downs J B, Kirby R R, Smith R A, Boysen P G, Lampotang S. Effects of expiratory flow resistance on inspiratory work of breathing. Chest . 1988; 93 795-799
66 Marini J J, Culver B H, Kirk W. Flow resistance of exhalation valves and positive end-expiratory pressure devices used in mechanical ventilation. Am Rev Respir Dis . 1985; 131 850-854
67 Pinsky M R, Hrehocik D, Culpepper J A, Snyder J V. Flow resistance of expiratory positive-pressure systems. Chest . 1988; 94 788-791
68 Rossi A, Appendini L. Wasted efforts and dyssynchrony: is the patient-ventilator battle back?. Intensive Care Med . 1995; 21 867-870
69 Kress J P, O'Connor M F, Schmidt G A. Clinical examination reliably detects intrinsic positive end-expiratory pressure in critically ill, mechanically ventilated patients. Am J Respir Crit Care Med . 1999; 159 290-294
70 Sassoon C SH, Giron A E, Ely E A, Light R W. Inspiratory work of breathing on flow-by and demand-flow continuous positive airway pressure. Crit Care Med . 1989; 17 1108-1114
71 Sydow M, Golisch W, Buscher H, Zinserling J, Crozier T A, Burchardi H. Effect of low-level PEEP on inspiratory work of breathing in intubated patients, both with healthy lungs and with COPD. Intensive Care Med . 1995; 21 887-895
72 Ranieri V M, Mascia L, Petruzzelli V, Bruno F, Brienza A, Giuliani R. Inspiratory effort and measurement of dynamic intrinsic PEEP in COPD patients: effects of ventilator triggering systems. Intensive Care Med . 1995; 21 896-903
73 Polese G, Massara A, Poggi R, Brandolese R, Brandi G, Rossi A. Flow-triggering reduces inspiratory effort during weaning from mechanical ventilation. Intensive Care Med . 1995; 21 682-686
74 Moran J L, Homan S, O'Fathartaigh M, Jackson M, Leppard P. Inspiratory work imposed by continuous positive airway pressure (CPAP) machines: the effect of CPAP level and endotracheal tube size. Intensive Care Med . 1992; 18 148-154
75 Branson R D, Campbell R S, Davis Jr K, Johnson 2nd J D. Comparison of pressure and flow triggering systems during continuous positive airway pressure. Chest . 1994; 106 540-544
76 Giuliani R, Mascia L, Recchia F, Caracciolo A, Fiore T, Ranieri V M. Patient-ventilator interaction during synchronized intermittent mandatory ventilation: effects of flow triggering. Am J Respir Crit Care Med . 1995; 151 1-9
77 Nishimura M, Imanaka H, Yoshiya I, Kacmarek R M. Comparison of inspiratory work of breathing between flow-triggered and pressure-triggered demand flow systems in rabbits. Crit Care Med . 1994; 22 1002-1009
78 Tutuncu A S, Cakar N, Camci E, Esen F, Telci L, Akpir K. Comparison of pressure- and flow-triggered pressure support ventilation on weaning parameters in patients recovering from acute respiratory failure. Crit Care Med . 1997; 25 756-760
79 Nava S, Bruschi C, Rubini F, Palo A, Iotti G, Braschi A. Respiratory response and inspiratory effort during pressure support ventilation in COPD patients. Intensive Care Med . 1995; 21 871-879
80 Purro A, Appendini L, De Gaetano A, Gudjonsdottir M, Donner C F, Rossi A. Physiologic determinants of ventilator dependence in long-term mechanically ventilated patients. Am J Respir Crit Care Med . 2000; 161 1115-1123
81 Alvisi R, Volta C, Righini E, Capuzzo M, Ragazzi R, Verri M. Predictors of weaning outcome in chronic obstructive pulmonary disease patients. Eur Respir J . 2000; 15 656-662
82 Nevins M, Epstein S. Predictors of outcome for patients with COPD requiring invasive mechanical ventilation. Chest 2001 (in press).
83 Messinger G, Banner M J, Blanch P B, Layon A J. Using tracheal pressure to trigger the ventilator and control airway pressure during continuous positive airway pressure decreases work of breathing. Chest . 1995; 108 509-514
84 Banner M J, Blanch P B, Kirby R R. Imposed work of breathing and methods of triggering a demand-flow, continuous positive airway pressure system. Crit Care Med . 1993; 21 183-190
85 MacIntyre N, Nishimura M, Usada Y, Tokioka H, Takezawa J, Shimada Y. The Nagoya Conference on system design and patient-ventilator interactions during pressure support ventilation. Chest . 1990; 97 1463-1466
86 Barnard M, Shukla A, Lovell T, Goldstone J. Esophageal-directed pressure support ventilation in normal volunteers. Chest . 1999; 115 482-489
87 Takahashi T, Takezawa J, Kimura T, Nishiwaki K, Shimada Y. Comparison of inspiratory work of breathing in T-piece breathing, PSV, and pleural pressure support ventilation (PPSV). Chest . 1991; 100 1030-1034
88 Messinger G, Banner M J. Tracheal pressure triggering a demand-flow continuous positive airway pressure system decreases patient work of breathing. Crit Care Med . 1996; 24 1829-1834
89 Guttmann J, Eberhard L, Fabry B, Bertschmann W, Wolff G. Continuous calculation of intratracheal pressure in tracheally intubated patients. Anesthesiology . 1993; 79 503-513
90 Bhatt S, Patel C, Tran I. Imposed work of breathing during tracheal pressure-triggering using a demand-valve CPAP system. Respir Care . 1996; 41 512-518
91 Sassoon C S, Lodia R, Rheeman C H, Kuei J H, Light R W, Mahutte C K. Inspiratory muscle work of breathing during flow-by, demand-flow, and continuous-flow systems in patients with chronic obstructive pulmonary disease. Am Rev Respir Dis . 1992; 145 1219-1222
92 Coggeshall J W, Marini J J, Newman J H. Improved oxygenation after muscle relaxation in adult respiratory distress syndrome. Arch Intern Med . 1985; 145 1718-1720
93 Viale J P, Annat G J, Bouffard Y M, Delafosse B X, Bertrand O M, Motin J P. Oxygen cost of breathing in postoperative patients: pressure support ventilation vs continuous positive airway pressure. Chest . 1988; 93 506-509
94 Annat G J, Viale J P, Dereymez C P, Bouffard Y M, Delafosse B X, Motin J P. Oxygen cost of breathing and diaphragmatic pressure time index: measurement in patients with COPD during weaning with pressure support ventilation. Chest . 1990; 98 411-414
95 Brochard L, Harf A, Lorino H, Lemaire F. Inspiratory pressure support prevents diaphragmatic fatigue during weaning from mechanical ventilation. Am Rev Respir Dis . 1989; 139 513-521
96 MacIntyre N R. Respiratory function during pressure support ventilation. Chest . 1986; 89 677-683
97 Elliott M W, Aquilina R, Green M, Moxham J, Simonds A K. A comparison of different modes of noninvasive ventilatory support: effects on ventilation and inspiratory muscle effort. Anaesthesia . 1994; 49 279-283
98 Knebel A R, Janson-Bjerklie S L, Malley J D, Wilson A G, Marini J J. Comparison of breathing comfort during weaning with two ventilatory modes. Am J Respir Crit Care Med . 1994; 149 14-18
99 Kreit J W, Capper M W, Eschenbacher W L. Patient work of breathing during pressure support and volume-cycled mechanical ventilation. Am J Respir Crit Care Med . 1994; 149 1085-1091
100 Parthasarathy S, Jubran A, Tobin M J. Assessment of neural inspiratory time in ventilator-supported patients. Am J Respir Crit Care Med . 2000; 162 546-552
101 Leatherman J W, Ravenscraft S A. Low measured auto-positive end-expiratory pressure during mechanical ventilation of patients with severe asthma: hidden auto-positive end-expiratory pressure. Crit Care Med . 1996; 24 541-546
102 Zakynthinos S G, Vassilakopoulos T, Zakynthinos E, Roussos C. Accurate measurement of intrinsic positive end-expiratory pressure: how to detect and correct for expiratory muscle activity. Eur Respir J . 1997; 10 522-529
103 Conti G, Vilardi V, Rocco M, DeBlasi R A, Lappa A, Bufi M. Paralysis has no effect on chest wall and respiratory system mechanics of mechanically ventilated, sedated patients. Intensive Care Med . 1995; 21 808-812
104 Gottfried S B, Reissman H, Ranieri V M. A simple method for the measurement of intrinsic positive end-expiratory pressure during controlled and assisted modes of mechanical ventilation. Crit Care Med . 1992; 20 621-629
105 Maltais F, Reissmann H, Navalesi P, Hernandez P, Gursahaney A, Ranieri V M. Comparison of static and dynamic measurements of intrinsic PEEP in mechanically ventilated patients. Am J Respir Crit Care Med . 1994; 150 1318-1324
106 Appendini L, Patessio A, Zanaboni S, Carone M, Gukov B, Donner C F. Physiologic effects of positive end-expiratory pressure and mask pressure support during exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med . 1994; 149 1069-1076
107 Lessard M R, Lofaso F, Brochard L. Expiratory muscle activity increases intrinsic positive end-expiratory pressure independently of dynamic hyperinflation in mechanically ventilated patients. Am J Respir Crit Care Med . 1995; 151 562-569
108 Corne S, Gillespie D, Roberts D, Younes M. Effect of inspiratory flow rate on respiratory rate in intubated ventilated patients. Am J Respir Crit Care Med . 1997; 156 304-308
109 Appendini L, Purro A, Patessio A, Zanaboni S, Carone M, Spada E. Partitioning of inspiratory muscle workload and pressure assistance in ventilator-dependent COPD patients. Am J Respir Crit Care Med . 1996; 154 1301-1309
110 Gay P C, Rodarte J R, Hubmayr R D. The effects of positive expiratory pressure on isovolume flow and dynamic hyperinflation in patients receiving mechanical ventilation. Am Rev Respir Dis . 1989; 139 621-626
111 Fessler H E, Brower R G, Permutt S. CPAP reduces inspiratory work more than dyspnea during hyperinflation with intrinsic PEEP. Chest . 1995; 108 432-440
112 Petrof B J, Legare M, Goldberg P, Milic-Emili J, Gottfried S B. 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; 141 281-289
113 Smith T C, Marini J J. Impact of PEEP on lung mechanics and work of breathing in severe airflow obstruction. J Appl Physiol . 1988; 65 1488-1499
114 Ranieri V, Giuliani R, Cinnella G, Pesce C, Brienza N, Ippolito E. Physiological effects 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
115 Van de Graaff B W, Gordey K, Dornseif S E, Dries D J, Kleinman B S, Kumar P. Pressure support: changes in ventilatory pattern and components of the work of breathing. Chest . 1991; 100 1082-1089
116 Fiastro J F, Habib M P, Quan S F. Pressure support compensation for inspiratory work due to endotracheal tubes and demand continuous positive airway pressure. Chest . 1988; 93 499-505
117 Berger K I, Sorkin I B, Norman R G, Rapoport D M, Goldringg R M. Mechanism of relief of tachypnea during pressure support ventilation. Chest . 1996; 109 1320-1327
118 Nathan S D, Ishaaya A M, Koerner S K, Belman M J. Prediction of minimal pressure support during weaning from mechanical ventilation. Chest . 1993; 103 1215-1219
119 Kimura T, Takezawa J, Nishiwaki K, Shimada Y. Determination of the optimal pressure support level evaluated by measuring transdiaphragmatic pressure. Chest . 1991; 100 112-117
120 Banner M J, Kirby R R, Kirton O C, DeHaven C B, Blanch P B. Breathing frequency and pattern are poor predictors of work of breathing in patients receiving pressure support ventilation. Chest . 1995; 108 1338-1344
121 Alberti A, Gallo F, Fongaro A, Valenti S, Rossi A. P0.1 is a useful parameter in setting the level of pressure support ventilation. Intensive Care Med . 1995; 21 547-553
122 Perrigault P F, Pouzeratte Y H, Jaber S, Capdevila X J, Hayot M, Boccara G. Changes in occlusion pressure (P0.1) and breathing pattern during pressure support ventilation. Thorax . 1999; 54 119-123
123 Calderini E, Confalonieri M, Puccio P G, Francavilla N, Stella L, Gregoretti C. Patient-ventilator asynchrony during noninvasive ventilation: the role of expiratory trigger. Intensive Care Med . 1999; 25 662-667
124 Kacmarek R M. NIPPV: patient-ventilator synchrony, the difference between success and failure?. Intensive Care Med . 1999; 25 645-647
125 Banner M J, Kirby R R, Blanch P B. Site of pressure measurement during spontaneous breathing with continuous positive airway pressure: effect on calculating imposed work of breathing. Crit Care Med . 1992; 20 528-533
126 Banner M J, Jaeger M J, Kirby R R. Components of the work of breathing and implications for monitoring ventilator-dependent patients. Crit Care Med . 1994; 22 515-523
127 Kirton O C, Banner M J, Axelrad A, Drugas G. Detection of unsuspected imposed work of breathing:case reports. Crit Care Med . 1993; 21 790-795
128 Guttmann J, Bernhard H, Mols G, Benzing A, Hofmann P, Haberthur C. Respiratory comfort of automatic tube compensation and inspiratory pressure support in conscious humans. Intensive Care Med . 1997; 23 1119-1124
129 Hess D, Branson R D. Ventilators and weaning modes. Respir Care Clin N Am. 2000; 6 407-435 v-vi
130 Younes M. Proportional assist ventilation, a new approach to ventilatory support. Theory Am Rev Respir Dis . 1992; 145 114-120
131 Ranieri V M, Giuliani R, Mascia L, Grasso S, Petruzzelli V, Puntillo N. Patient-ventilator interaction during acute hypercapnia: pressure support versus proportional-assist ventilation. J Appl Physiol . 1996; 81 426-436
132 Amato M B, Barbas C S, Bonassa J, Saldiva P H, Zin W A, de Carvalho R C. Volume-assured pressure support ventilation (VAPSV): a new approach for reducing muscle workload during acute respiratory failure. Chest . 1992; 102 1225-1234
133 MacIntyre N R, Gropper C, Westfall T. Combining pressure-limiting and volume-cycling features in a patient-interactive mechanical breath. Crit Care Med . 1994; 22 353-357
134 Keenan H, Martin L. Volume support ventilation in infants and children: analysis of a case series. Respir Care . 1997; 42 281-287
135 Weiler N, Eberle B, Latorre F, von Paczynski S, Heinrichs W. [Adaptive lung ventilation (AVL): evaluation of new closed loop regulated respiration algorithm for operation in the hyperextended lateral position]. Anaesthesist . 1996; 45 950-956