Classifying reverse triggering breaths: A clinically oriented approach

Adrian Gallardo, Mauro Castro Sayat, Aldana Silvero, Juan Martin Núñez Silveira

Abstract

Asynchronies during mechanical ventilation, particularly reverse triggering (RT), is a common phenomenon in critically ill patients, with prevalence estimates between 30% and 60%. RT is characterized by the activation of respiratory muscles induced by the passive insufflation, which can impact pulmonary physiology and diaphragmatic function, increasing the risk of lung injury and muscle damage. The proposed classification of RT in this article is based on five key criteria which suppose a structured evaluation of RT phenotypes.

This classification criteria would allow differentiation between events that may be beneficial, such as maintaining diaphragm activity and improving oxygenation, and injurious episodes, including breath stacking and high efforts that exacerbate pulmonary and muscular injury.

Understanding and classifying RT in detail enables clinicians to make more precise decisions and implement personalized interventions, thereby improving the safety and effectiveness of mechanical ventilation in critical care settings. This comprehensive approach provides a foundation for future research to validate its clinical utility, identify high-risk patient phenotypes, and develop targeted therapies.

Keywords:  reverse trigger, phenotypes, classification, timing

References

1. Blanch L, Villagra A, Sales B, et al. Asynchronies during mechanical ventilation are associated with mortality. Intensive Care Med 2015; 41(4):633-41. https://doi.org/10.1007/s00134-015-3692-6 PMid:25693449

2. Thille AW, Rodriguez P, Cabello B, et al. Patient-ventilator asynchrony during assisted mechanical ventilation. Intensive Care Med 2006 ;32(10):1515-22. https://doi.org/10.1007/s00134-006-0301-8 PMid:16896854

3 Vaporidi K, Babalis D, Chytas A, et al. Clusters of ineffective efforts during mechanical ventilation: impact on outcome. Intensive Care Med 2017; 43(2):184-191. https://doi.org/10.1007/s00134-016-4593-z PMid:27778044

4. Akoumianaki E, Lyazidi A, Rey N, et al. Mechanical ventilation-induced reverse-triggered breaths: a frequently unrecognized form of neuromechanical coupling. Chest. 2013; 143(4):927-938. https://doi.org/10.1378/chest.12-1817 PMid:23187649

5. Jackson R, Kim A, Moroz N, et al. Reverse triggering ? a novel or previously missed phenomenon? Ann Intensive Care 2024; 14(1):78. https://doi.org/10.1186/s13613-024-01303-4 PMid:38776032 PMCid:PMC11111438

6. Simon PM, Zurob AS, Wies WM, et al. Entrainment of respiration in humans by periodic lung inflations. Effect of state and CO(2). Am J Respir Crit Care Med 1999; 160(3):950-960. https://doi.org/10.1164/ajrccm.160.3.9712057 PMid:10471624

7. Potts JT, Rybak IA, Paton JF. Respiratory rhythm entrainment by somatic afferent stimulation. J Neurosci 2005; 25(8):1965-1978. https://doi.org/10.1523/JNEUROSCI.3881-04.2005 PMid:15728836 PMCid:PMC6726065

8. Simon PM, Habel AM, Daubenspeck JA, et al. Vagal feedback in the entrainment of respiration to mechanical ventilation in sleeping humans. J Appl Physiol (1985). 2000; 89(2):760-769. https://doi.org/10.1152/jappl.2000.89.2.760 PMid:10926663

9. Delisle S, Charbonney E, Albert M, et al. Patient-ventilator asynchrony due to reverse triggering occurring in brain-dead patients: Clinical implications and physiological meaning. Am J Respir Crit Care Med 2016; 194(9):1166-1168. https://doi.org/10.1164/rccm.201603-0483LE PMid:27797612

10. Baedorf Kassis E, Su HK, Graham AR, et al. Reverse trigger phenotypes in acute respiratory distress syndrome. Am J Respir Crit Care Med 2021; 203(1):67-77. https://doi.org/10.1164/rccm.201907-1427OC PMid:32809842 PMCid:PMC7781129

11. Hashimoto H, Yoshida T, Firstiogusran AMF, et al. Asynchrony injures lung and diaphragm in acute respiratory distress syndrome. Crit Care Med 2023; 51(11):e234-e242. https://doi.org/10.1097/CCM.0000000000005988 PMid:37459198

12. Lin WC, Su PF, Chen CW. Pendelluft in patients with acute respiratory distress syndrome during trigger and reverse triggering breaths. Sci Rep 2023; 13, 22143. https://doi.org/10.1038/s41598-023-49038-9 PMid:38092775 PMCid:PMC10719360

13. Graves C, Glass L, Laporta D, et al. Respiratory phase locking during mechanical ventilation in anesthetized human subjects. Am J Physiol 1986; 250(5 Pt 2):R902-909. https://doi.org/10.1152/ajpregu.1986.250.5.R902 PMid:3706575

14. de Vries HJ, Jonkman AH, Tuinman PR, et al. Respiratory entrainment and reverse triggering in a mechanically ventilated patient. Ann Am Thorac Soc 2019; 16(4):499-505. https://doi.org/10.1513/AnnalsATS.201811-767CC PMid:30932701

15. Haas F, Distenfeld S, Axen K. Effects of perceived musical rhythm on respiratory pattern. J Appl Physiol (1985) 1986; 61(3):1185-1191. https://doi.org/10.1152/jappl.1986.61.3.1185 PMid:3759758

16. Remmers JE, Marttila I. Action of intercostal muscle afferents on the respiratory rhythm of anesthetized cats. Respir Physiol 1975; 24(1):31-41. https://doi.org/10.1016/0034-5687(75)90119-X PMid:1197945

17. Reinoso MA, Sieck GC, Hubmayr RD. Respiratory muscle coordination in acute spinal dogs. Respir Physiol 1996; 104(1):29-37. https://doi.org/10.1016/0034-5687(95)00097-6 PMid:8865379

18. Chen BY, Vasilakos K, Boisteanu D, et al. Linkage of hiccup with heartbeat. J Appl Physiol (1985) 2000; 88:2159-2165. https://doi.org/10.1152/jappl.2000.88.6.2159 PMid:10846031

19. Rodriguez PO, Tiribelli N, Fredes S, et al; Grupo Argentino de Estudio de Asincronías en la Ventilación Mecánica Study Group. Prevalence of reverse triggering in early ards: Results from a multicenter observational study. Chest 2021; 159(1):186-195. https://doi.org/10.1016/j.chest.2020.08.018 PMid:32805238

20. Damiani LF, Engelberts D, Bastia L, et al. Impact of reverse triggering dyssynchrony during lung-protective ventilation on diaphragm function: An experimental model. Am J Respir Crit Care Med 2022; 205(6):663-673. https://doi.org/10.1164/rccm.202105-1089OC PMid:34941477

21. Longhini F, Simonte R, Vaschetto Ret al. Reverse triggered breath during pressure support ventilation and neurally adjusted ventilatory assist at increasing propofol infusion. J Clin Med 2023; 12(14):4857. https://doi.org/10.3390/jcm12144857 PMid:37510970 PMCid:PMC10381884

22. Murias G, Villagra A, Blanch L. Patient-ventilator dyssynchrony during assisted invasive mechanical ventilation. Minerva Anestesiol 2013; 79(4):434-444.

23. Plens GM, Morais CC, Nakamura Maet al. Effect of cardiogenic oscillations on trigger delay during pressure support ventilation. Respir Care 2018; 63(7):865-872. https://doi.org/10.4187/respcare.05995 PMid:29895701

24. Imanaka H, Nishimura M, Takeuchi M, et al. Autotriggering caused by cardiogenic oscillation during flow-triggered mechanical ventilation. Crit Care Med 2000; 28(2):402-407. https://doi.org/10.1097/00003246-200002000-00019 PMid:10708174

25. Ruiz Ferrón F, Serrano Simón JM. Trigger reverse identification in critical care setting. Med Intensiva (Engl Ed). 2018; 42(6):391-393. https://doi.org/10.1016/j.medin.2017.04.002 PMid:28502646

26. Akoumianaki E, Bolaki M, Prinianakis G, et al. Hiccup-like contractions in mechanically ventilated patients: individualized Treatment guided by transpulmonary pressure. J Pers Med 2023; 13(6):984. https://doi.org/10.3390/jpm13060984 PMid:37373973 PMCid:PMC10301282

27. Menga LS, Cammareri G, Jovanovic T, et al. Diaphragm myoclonus-induced autotriggering during neurally adjusted ventilatory assist. Intensive Care Med 2018; 44(12):2309-2311. https://doi.org/10.1007/s00134-018-5430-3 PMid:30367187

28. Vignaux L, Vargas F, Roeseler J, et al. Patient-ventilator asynchrony during non-invasive ventilation for acute respiratory failure: a multicenter study. Intensive Care Med 2009; 35(5):840-846. https://doi.org/10.1007/s00134-009-1416-5 PMid:19183949

29. Jonkman AH, Holleboom MC, de Vries HJ, et al. Expiratory muscle relaxation-induced ventilator triggering: A novel patient-ventilator dyssynchrony. Chest 2022; 161(6):e337-e341. https://doi.org/10.1016/j.chest.2022.01.070 PMid:35680312 PMCid:PMC9248081

30. Benítez Lozano JA, de la Fuente Martos C, Serrano Simón JM. Double trigger and Pseudo-reverse-trigger? Med Intensiva (Engl Ed). 2021; 45(7):e15-e17. https://doi.org/10.1016/j.medine.2021.07.003 PMid:34294564