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Automatic tube compensation and proportional assist ventilation Clinical experience with these new modes of pressure support in intubated spontaneously breathing patients



Automatic tube compensation and proportional assist ventilation Clinical experience with these new modes of pressure support in intubated spontaneously breathing patients



Intensivmedizin und Notfallmedizin 33(4): 282-292



"Triggered inspiratory pressure support ventilation (IPS)" is commonly used to support inspiration in intubated spontaneously breathing patients. Despite its usefulness, IPS shows some disadvantages which can be deleterious in critically ill patients: 1) additional work of breathing to be performed by the patient due to the flow-dependent tube resistance, 2) desynchronization between patient and ventilator, and 3) discrepancy between the uniform pressure support and the patient's variable breathing pattern. Whereas the new mode "proportional assist ventilation (PAV)" avoids desynchronization and misstriggering and can adapt the pressure support to the patient's needs, it is unable to compensate adequately for the additional work of breathing caused by the flow-dependent tube resistance. Only in combination with "automatic tube compensation (ATC)," the mode developed at our institute to generate complete automatic compensation for the flow-dependent tube resistance during in- and expiration ("electronic extubation"), the advantages of PAV can be fully realized. Thus, based on the examination of 55 intubated, spontaneously breathing patients, we are able to show that 1) ATC with/without PAV effectively frees the patient of most of the additional work of breathing caused by the tube resistance, 2) ATC with/without PAV completely avoids desynchronization and misstriggering, 3) ATC with/without PAV allows the patient to breathe with his/her own inherent breathing pattern, and that 4) the breathing pattern found under "electronic extubation" in the ATC mode permits a safe prediction with respect to the success of actual physical extubation. A possible limitation to the application of PAV may be imposed by our observation that PAV intensifies periodic breathing, a pattern which we found in 42% of intubated critically ill patients. In addition, future studies must establish whether patients in the early phase of weaning from mechanical ventilation have adequate control of breathing for the application of ATC with/without PAV. To sum up, we can conclude that the new mode ATC with/without PAV allows a more physiological ventilatory support and overcomes the disadvantages of conventional modes of pressure support in intubated spontaneously breathing patients.

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