Mortality associated with the acute respiratory distress syndrome remains unacceptably high due in part to ventilator-induced lung injury (VILI). Ventilator dyssynchrony is defined as the inappropriate timing and delivery of a mechanical breath in response to patient effort and may cause VILI. Such deleterious patient–ventilator interactions have recently been termed patient self-inflicted lung injury. This narrative review outlines the detection and frequency of several different types of ventilator dyssynchrony, delineates the different mechanisms by which ventilator dyssynchrony may propagate VILI, and reviews the potential clinical impact of ventilator dyssynchrony. Until recently, identifying ventilator dyssynchrony required the manual interpretation of ventilator pressure and flow waveforms. However, computerized interpretation of ventilator waive forms can detect ventilator dyssynchrony with an area under the receiver operating curve of >0.80. Using such algorithms, ventilator dyssynchrony occurs in 3%–34% of all breaths, depending on the patient population. Moreover, two types of ventilator dyssynchrony, double-triggered and flow-limited breaths, are associated with the more frequent delivery of large tidal volumes >10 mL/kg when compared with synchronous breaths (54% [95% confidence interval (CI), 47%–61%] and 11% [95% CI, 7%–15%]) compared with 0.9% (95% CI, 0.0%–1.9%), suggesting a role in propagating VILI. Finally, a recent study associated frequent dyssynchrony-defined as >10% of all breaths-with an increase in hospital mortality (67 vs. 23%, P = 0.04). However, the clinical significance of ventilator dyssynchrony remains an area of active investigation and more research is needed to guide optimal ventilator dyssynchrony management.


中文翻译：

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呼吸机不同步——检测、病理生理学和临床相关性：叙事评论


与急性呼吸窘迫综合征相关的死亡率仍然高得令人无法接受，部分原因是呼吸机引起的肺损伤 (VILI)。呼吸机不同步被定义为响应患者的努力而机械呼吸的时机和输送不当，并可能导致 VILI。这种有害的患者-呼吸机相互作用最近被称为患者自身造成的肺损伤。这篇叙述性综述概述了几种不同类型的呼吸机不同步的检测和频率，描述了呼吸机不同步可能传播 VILI 的不同机制，并回顾了呼吸机不同步的潜在临床影响。直到最近，识别呼吸机不同步还需要人工解释呼吸机压力和流量波形。然而，呼吸机豁免表格的计算机化解释可以检测呼吸机不同步，受试者工作曲线下面积 >0.80。使用此类算法，呼吸机不同步发生在所有呼吸的 3%–34% 中，具体取决于患者群体。此外，与同步呼吸相比，两种呼吸机不同步，双触发呼吸和流量限制呼吸与更频繁地输送大于 10 mL/kg 的大潮气量有关（54% [95% 置信区间 (CI)， 47%–61%] 和 11% [95% CI，7%–15%]）与 0.9%（95% CI，0.0%–1.9%）相比，表明在传播 VILI 中起作用。最后，最近的一项研究将频繁不同步（定义为所有呼吸的 10% 以上）与住院死亡率的增加相关联（67% vs. 23%，P = 0.04）。然而，呼吸机不同步的临床意义仍然是一个积极研究的领域，需要更多的研究来指导最佳的呼吸机不同步管理。