Autotriggering caused by cardiogenic oscillation during flow-triggered mechanical ventilation.
OBJECTIVE
We noticed that in some patients after cardiac surgery, when flow triggering was used, cardiogenic oscillation might be autotriggering the ventilatory support. In a prospective study, we evaluated the degree of cardiogenic oscillation and the frequency rate of autotriggering. We suspected that autotriggering caused by cardiogenic oscillation was more common than clinically appreciated.


METHODS
Prospective, nonrandomized, clinical study.


METHODS
Surgical intensive care unit in a national heart institute.


METHODS
A total of 104 adult patients were enrolled after cardiac surgery.


METHODS
During the study period, patients were paralyzed and ventilated with intermittent mandatory ventilation at a rate of 10 breaths/min, pressure support of 10 cm H2O, and flow triggering with a sensitivity of 1 L/min.


RESULTS
Because the patients would not be able to breathe spontaneously, we counted pressure-support (PS) breaths as instances of autotriggering. Then, we classified the patients into two groups according to the number of PS breaths: an "AT group" (PS breaths of >5/min) and a "non-AT group" (PS breaths of < or =5/min). If autotriggering occurred, we decreased the sensitivity so autotriggering disappeared (threshold triggering sensitivity). The intensity of cardiogenic oscillation was assessed as the flow and airway pressure at the airway opening. A total of 23 patients (22%) demonstrated more than five autotriggered breaths/min. During mechanical ventilation, the inspiratory flow fluctuation caused by cardiogenic oscillation was significantly greater in the AT group than in the non-AT group (4.67+/-1.26 L/min vs. 2.03+/-0.86 L/min; p<.01). The AT group also showed larger cardiac output, higher ventricular filling pressures, larger heart size, and lower respiratory system resistance than the non-AT group. As the inspiratory flow fluctuation caused by cardiogenic oscillation increased, the level of triggering sensitivity also was increased to avoid autotriggering. In the AT group with 1 L/min of sensitivity, the respiratory rate increased (19.9+/-2.7 vs. 10+/-0 breaths/min, p<.01), Paco2 decreased (30.8+/-4.0 torr [4.11+/-0.36 kPa] vs. 37.6+/-4.3 torr [5.01+/-0.57 kPa]; p < .01), and mean esophageal pressure increased (7.7+/-3.0 vs. 6.9+/-3.0 cm H2O; p<.01) compared with the threshold triggering sensitivity.


CONCLUSIONS
Autotriggering caused by cardiogenic oscillation is common in postcardiac surgery patients when flow triggering is used. Autotriggering occurred more often in patients with more dynamic circulation. Autotriggering caused respiratory alkalosis and hyperinflation of the lungs.
Imanaka
H
H
Surgical Intensive Care Unit, National Cardiovascular Center, Osaka, Japan. imanakah@hsp.ncvc.go.jp
Nishimura
M
M
Takeuchi
M
M
Kimball
W R
WR
Yahagi
N
N
Kumon
K
K
D000328:Adult; D000368:Aged; D000472:Alkalosis, Respiratory / Q000209:etiology* / Q000378:metabolism / Q000517:prevention & control; D001784:Blood Gas Analysis; D002138:Calibration; D006348:Cardiac Surgical Procedures; D004868:Equipment Failure; D005246:Feedback; D005260:Female; D006321:Heart / Q000502:physiology*; D006439:Hemodynamics; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009991:Oscillometry; D011175:Positive-Pressure Respiration / Q000009:adverse effects* / Q000379:methods*; D018467:Positive-Pressure Respiration, Intrinsic / Q000209:etiology* / Q000378:metabolism / Q000517:prevention & control; D011446:Prospective Studies; D015656:Respiratory Mechanics; D012307:Risk Factors; D012680:Sensitivity and Specificity