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Matt Siuba
Zentensivist. ARDS, Mechanical Ventilation, RV, & Shock Enthusiast.
The Pre-brief
A Bedside Warrior comes to you and says “my patient is bucking the vent, can you take a look?”
You see this characteristic pattern repeatedly:
You recognize this as “Double Triggering”, which may be more appropriately termed “Multiple Triggering” since it can involve more than two breaths back-to-back. Your mind starts to consider what to do next: more sedation, paralyze, something else?
As it happens, there are at least three distinct causes of multiple triggering! Check them out in the infographic below.
The De-Brief
- Multiple triggering is associated with worse outcomes; whether it is causative is unknown. Either way, mitigating it would be beneficial for patient comfort and to possibly decrease risk of ventilator-associated lung injury
- Not all “breath stacking” has the same cause which is relevant as the treatment for each type will differ
- More sedation is not the answer for all dyssynchrony! In fact, a recent study showed the respiratory drive and depth of sedation are not necessarily well correlated.
Further Reading
- For more on assessment of respiratory effort, see this post
- Want more info on assessing vent waveforms? Check out Parts 1 and 2 from Beyond Albuterol.
Ready to tackle more dyssynchronies? Check out my post on Failed Triggering.
References
- Chatburn RL, Mireles-Cabodevila E. 2019 Year in Review: Patient-Ventilator Synchrony. Respir Care. 2020;65(4):558-572. doi:10.4187/respcare.07635
- Sousa, Mayson Laérciod e Araújo PT, PhD1,2; Magrans, Rudys PhD3,4; Hayashi, Fátima K. RRT, PhD1,2; Blanch, Lluís MD, PhD3,4; Kacmarek, Robert M. RRT, PhD5,6,†; Ferreira, Juliana C. MD, PhD1 Clusters of Double Triggering Impact Clinical Outcomes, Critical Care Medicine: April 21, 2021 – Volume – Issue – doi: 10.1097/CCM.0000000000005029
- Dzierba, Amy L. PharmD1,2; Khalil, Anas M. MD3; Derry, Katrina L. PharmD4; Madahar, Purnema MD, MS1,5; Beitler, Jeremy R. MD, MPH1,5 Discordance Between Respiratory Drive and Sedation Depth in Critically Ill Patients Receiving Mechanical Ventilation, Critical Care Medicine: June 9, 2021 – Volume – Issue – doi: 10.1097/CCM.0000000000005113
