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Original Research: Critical Care |

Mechanical Ventilation-Induced Reverse-Triggered BreathsReverse Triggering: A Frequently Unrecognized Form of Neuromechanical Coupling

Evangelia Akoumianaki, MD; Aissam Lyazidi, PhD; Nathalie Rey, MD; Dimitrios Matamis, MD; Nelly Perez-Martinez, MD; Raphael Giraud, MD; Jordi Mancebo, MD; Laurent Brochard, MD; Jean-Christophe Marie Richard, MD, PhD
Author and Funding Information

From the Intensive Care Unit Division (Drs Akoumianaki, Lyazidi, Rey, Matamis, Perez-Martinez, Giraud, Brochard, Richard), Anesthesiology Pharmacology and Intensive Care Department, and the School of Medicine (Drs Lyazidi, Brochard, and Richard), University of Geneva, Geneva, Switzerland; and Hospital Sant Pau (Dr Mancebo), Servei de Medicina Intensiva, Barcelona, Spain.

Correspondence to: Jean-Christophe M. Richard, MD, PhD, Soins Intensifs, Hopitaux Universitaires de Genève, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva 14, Switzerland; e-mail: jcm.richard@hcuge.ch


Funding/Support: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;143(4):927-938. doi:10.1378/chest.12-1817
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Background:  Diaphragmatic muscle contractions triggered by ventilator insufflations constitute a form of patient-ventilator interaction referred to as “entrainment,” which is usually unrecognized in critically ill patients. Our objective was to review tracings, which also included muscular activity, obtained in sedated patients who were mechanically ventilated to describe the entrainment events and their characteristics. The term “reverse triggering” was adopted to describe the ventilator-triggered muscular efforts.

Methods:  Over a 3-month period, recordings containing flow, airway pressure, and esophageal pressure or electrical activity of the diaphragm were reviewed. Recordings were obtained from a series of consecutive heavily sedated patients ventilated with an assist-control mode of ventilation for ARDS. The duration of entrainment, the entrainment ratio, and the phase difference elapsing between the commencement of the ventilator and neural breaths were evaluated.

Results:  The tracings of eight consecutive patients with ARDS were reviewed; they all showed different forms of entrainment. Reverse triggering occurred over a portion varying from 12% to 100% of the total recording period. Seven patients had a 1:1 mechanical insufflation to diaphragmatic contractions ratio; this coexisted with a 1:2 ratio in one patient and 1:2 and 1:3 ratios in another. One patient exhibited only a 1:2 ratio. The frequency of reverse-triggered breaths had a mean coefficient of variability of < 5%, very close to the variability of mechanical breaths.

Conclusions:  To our knowledge, this is the first time that the presence of respiratory entrainment in sedated, critically ill adult patients who are mechanically ventilated has been documented. The “reverse-triggered” breaths illustrate a new form of neuromechanical coupling with potentially important clinical consequences.

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