Reverse Triggering, A Missed Phenomenon in the Literature
CCCF ePoster library. Telias I. 11/13/19; 283437; EP134
Dr. Irene Telias
Dr. Irene Telias
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Topic: Systematic Review, Meta-Analysis, or Meta-Synthesis

Telias, I2,3 Kim, A1;;Moroz N1Piraino T4; Damiani F2,3;Brochard L2,3
1 Keenan Research Summer Student Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada; 2 Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada; 3  Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada; 4 Department of Respiratory Therapy, St Michael's Hospital, Toronto, Canada

BACKGROUND: Reverse triggering (RT) is a type of asynchrony that can occur during mechanical ventilation (MV). RT is defined by the presence of patient's inspiratory effort after mechanical insufflation (i.e. triggered by the ventilator)1. The presence of RT was recently described in deeply sedated patients with acute respiratory distress syndrome (ARDS) but this asynchrony is thought to have existed previously3. Asynchronies have been associated with poor outcomes5. RT in particular might be injurious for the lung and the diaphragm. However, little clinical relevance is known on the effects of RT probably because of longstanding omission. Accurate recognition of RT at the bedside is necessary in order to further understand the phenomenon and to study its clinical effects.  
OBJECTIVES: A systematic review to identify the frequency of RT present in respiratory waveforms but not described in papers describing asynchronies up until 2017.
METHODS:  Medline and EMBASE databases were searched utilizing key words related to asynchrony and MV. Included manuscripts were those containing respiratory waveforms that are used to detect RT (airway pressure (Paw) and flow with or without esophageal pressure (Peso) or electrical activity of the diaphragm (EAdi)). Excluded manuscripts were studies involving animals, non-invasive ventilation, neonate (only), infant (only), lack of availability, conference abstracts, high frequency oscillation ventilation, cardiac synchronization, thoraco-abdominal synchrony, negative pressure ventilation and spontaneous modes of ventilation. Each tracing from the included manuscripts was analyzed for the presence of RT (definite or possible) using predefined criteria by two experts and assessing if it was missed by the original authors. Possible RT was defined as figures that only contain flow and Paw tracings but display an abnormality in the waveform that may indicate patient effort following a machine-triggered breath. Definite RT was defined as having flow and Paw with Peso or EAdi tracings that indicate a patient effort (i.e. negative deflection in Peso or positive deflection in EAdi) following a machine-triggered breath. RT was missed when no reference to the phenomenon was found in the paper (“reverse triggering” or “entrainment”).
RESULTS: 2700 citations were screened; 963 manuscripts were eligible for full-text screening. A total of 963 full text articles were retrieved, 711 manuscripts have been excluded for the lack of appropriate tracings. For the final analysis, 163 manuscripts published between 1965 - 2017 were included. From this, 721 figures have been analyzed, with 41 (5.7%) of them accounting for possible (n=22) or definite (n=19) RT. RT was incorrectly described in 26 (63%) of them. Manuscripts published before RT was described had 100% of the waveforms with missed RT, whereas manuscripts published after RT was described had 25% of waveforms with missed RT.
CONCLUSIONS: Final results indicate that RT is a frequent phenomenon and has been missed commonly in previously published papers.

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  1. Akoumianaki E, Lyazidi A, Rey N, Matamis D, Perez-Martinez N, Giraud R, Mancebo J, Brochard L, Richard JC. Mechanical ventilation-induced reverse-triggered breaths: A frequently unrecognized form of neuromechanical coupling. Chest. 2013 Apr 1;143(4):927-38.
  2. Chanques G, Kress JP, Pohlman A, Patel S, Poston J, Jaber S, Hall JB. Impact of ventilator adjustment and sedation–analgesia practices on severe asynchrony in patients ventilated in assist-control mode. Critical Care Medicine. 2013 Sep 1;41(9):2177-87.
  3. Graves CA, Glass LE, Laporta DO, Meloche RO, Grassino AL. Respiratory phase locking during mechanical ventilation in anesthetized human subjects. American Journal of Physiology-Regulatory, Integrative and Comparative Physiology. 1986 May 1;250(5):R902-9.
  4. Kallet RH, Campbell AR, Dicker RA, Katz JA, Mackersie RC. Work of breathing during lung-protective ventilation in patients with acute lung injury and acute respiratory distress syndrome: A comparison between volume and pressure-regulated breathing modes. Respiratory Care. 2005 Dec 1;50(12):1623-31.
  5. Mellott KG, Grap MJ, Munro CL, Sessler CN, Wetzel PA, Nilsestuen JO, Ketchum JM. Patient ventilator asynchrony in critically ill adults: Frequency and types. Heart & Lung: The Journal of Acute and Critical Care. 2014 May 1;43(3):231-43.
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