title: Assessment of patient-ventilator breath contribution during neurally adjusted ventilatory assist in patients with acute respiratory failure.
abstract: BACKGROUND
  We previously showed in animals that the ratio of inspired tidal volume (Vtinsp) to inspiratory peak electrical activity of the diaphragm (EAdipk) can be used to quantify the respective patient and ventilator breath contributions (PVBCs) during neurally adjusted ventilatory assist (NAVA). The PVBC index has not been tested clinically.
  
  
  METHODS
  We studied 12 intubated and mechanically ventilated patients with acute respiratory failure and measured EAdipk, airway (Paw) and inspiratory esophageal pressure (Pes) and Vtinsp. We applied 11 different NAVA levels, increasing them every 3 minutes in steps of 0.3 cm H₂O/μV from 0 to 3.0 cmH₂O/μV. At each NAVA level, one breath was non-assisted (NAVA level 0). PVBC indices were calculated by relating Vtinsp/EAdipk of the non-assisted breath to Vtinsp/EAdipk of the assisted breath(s) using one ((N1)PVBC) or the mean value of five preceding assisted breaths ((X5)PVBC). During assisted breaths, inspiratory changes in Pes (∆Pes) and transpulmonary (ΔPtp) pressures were used to calculate the relative contribution of patient to total inspiratory lung-distending pressures (ΔPes/ΔPtp). Matching of respiratory drive indices and squaring of the PVBC was evaluated for their effect on the correlation between PVBC and ΔPes/ΔPtp. Linear regression analysis and Bland-Altman analysis were applied to compare indices.
  
  
  RESULTS
  Using an average of five assisted breaths prior to the non-assisted breath and squaring the PVBC ((X5)PVBC(2)) improved determination coefficients (P <0.05), adjusted the regression slope and intercept between PVBC and ΔPes/ΔPtp toward identity (P <0.05) and reduced bias (P <0.05). Matching EAdipk between non-assisted and assisted breaths within the range of 0.77 to 1.30 improved the relationship between (X5)PVBC(2) and ΔPes/ΔPtp (P <0.05) and abolished the need for EAdi normalization in the PVBC calculation (R(2) = 0.96; bias = 0.16 ± 0.06; precision = 0.33 ± 0.08 (mean and 95% confidence interval)).
  
  
  CONCLUSIONS
  This clinical study confirms previous experimental results showing that the PVBC(2) predicts the contribution of the inspiratory muscles versus that of the ventilator during NAVA, when differences in effort (EAdi) between non-assisted and assisted breaths are limited. PVBC could help to quantify and standardize the adjustment of the level of assist, and hence reduce the risks of excessive ventilatory assist in patients.
  
  
  BACKGROUND
  ClinicalTrials.gov NCT01663480. Registered 9 August 2012.
authors.affiliation: Department of Critical Care Medicine, Zhongda Hospital, Southeast University, School of Medicine, 87 Dingjiaqiao Street, Nanjing, 210009, China. liulingdoctor@126.com.
authors.forename: Ling
authors.initials: L
authors.lastname: Liu
authors.affiliation: Department of Critical Care Medicine, Zhongda Hospital, Southeast University, School of Medicine, 87 Dingjiaqiao Street, Nanjing, 210009, China. liusongqiao@ymail.com.
authors.forename: Songqiao
authors.initials: S
authors.lastname: Liu
authors.affiliation: Department of Critical Care Medicine, Zhongda Hospital, Southeast University, School of Medicine, 87 Dingjiaqiao Street, Nanjing, 210009, China. xie820405@126.com.
authors.forename: Jianfeng
authors.initials: J
authors.lastname: Xie
authors.affiliation: Department of Critical Care Medicine, Zhongda Hospital, Southeast University, School of Medicine, 87 Dingjiaqiao Street, Nanjing, 210009, China. yiyiyang2004@163.com.
authors.forename: Yi
authors.initials: Y
authors.lastname: Yang
authors.affiliation: Keenan Research Centre for Biomedical Science and Department of Critical Care, St Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada. slutskya@smh.ca.|Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Suit RFE3-805, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada. slutskya@smh.ca.
authors.forename: Arthur S
authors.initials: AS
authors.lastname: Slutsky
authors.affiliation: Keenan Research Centre for Biomedical Science and Department of Critical Care, St Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada. jennifer.beck@rogers.com.|Department of Pediatrics, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada. jennifer.beck@rogers.com.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Beck
authors.affiliation: Keenan Research Centre for Biomedical Science and Department of Critical Care, St Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada. sinderby@rogers.com.|Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Suit RFE3-805, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada. sinderby@rogers.com.
authors.forename: Christer
authors.initials: C
authors.lastname: Sinderby
authors.affiliation: Department of Critical Care Medicine, Zhongda Hospital, Southeast University, School of Medicine, 87 Dingjiaqiao Street, Nanjing, 210009, China. haiboq2000@163.com.
authors.forename: Haibo
authors.initials: H
authors.lastname: Qiu
mesh_terms: D003964:Diaphragm / Q000502:physiology; D006801:Humans; D059725:Interactive Ventilatory Support / Q000379:methods*; D012128:Respiratory Distress Syndrome / Q000503:physiopathology / Q000628:therapy*; D012132:Respiratory Muscles / Q000502:physiology*; D012815:Signal Processing, Computer-Assisted; D013990:Tidal Volume / Q000502:physiology