Patient-ventilator asynchrony during noninvasive ventilation: a bench and clinical study.

BACKGROUND: Different kinds of ventilators are available to perform noninvasive ventilation (NIV) in ICUs. Which type allows the best patient-ventilator synchrony is unknown. The objective was to compare patient-ventilator synchrony during NIV between ICU, transport-both with and without the NIV algorithm engaged-and dedicated NIV ventilators. METHODS: First, a bench model simulating spontaneous breathing efforts was used to assess the respective impact of inspiratory and expiratory leaks on cycling and triggering functions in 19 ventilators. Second, a clinical study evaluated the incidence of patient-ventilator asynchronies in 15 patients during three randomized, consecutive, 20-min periods of NIV using an ICU ventilator with and without its NIV algorithm engaged and a dedicated NIV ventilator. Patient-ventilator asynchrony was assessed using flow, airway pressure, and respiratory muscles surface electromyogram recordings. RESULTS: On the bench, frequent auto-triggering and delayed cycling occurred in the presence of leaks using ICU and transport ventilators. NIV algorithms unevenly minimized these asynchronies, whereas no asynchrony was observed with the dedicated NIV ventilators in all except one. These results were reproduced during the clinical study: The asynchrony index was significantly lower with a dedicated NIV ventilator than with ICU ventilators without or with their NIV algorithm engaged (0.5% [0.4%-1.2%] vs 3.7% [1.4%-10.3%] and 2.0% [1.5%-6.6%], P < .01), especially because of less auto-triggering. CONCLUSIONS: Dedicated NIV ventilators allow better patient-ventilator synchrony than ICU and transport ventilators, even with their NIV algorithm. However, the NIV algorithm improves, at least slightly and with a wide variation among ventilators, triggering and/or cycling off synchronization.

Patient-ventilator asynchrony during non-invasive ventilation for acute respiratory failure: a multicenter study.

OBJECTIVE : To determine the prevalence of patient-ventilator asynchrony in patients receiving non-invasive ventilation (NIV) for acute respiratory failure. DESIGN : Prospective multicenter observation study. SETTING : Intensive care units in three university hospitals. METHODS: Patients consecutively admitted to ICU were included. NIV, performed with an ICU ventilator, was set by the clinician. Airway pressure, flow, and surface diaphragmatic electromyography were recorded continuously for 30 min. Asynchrony events and the asynchrony index (AI) were determined from visual inspection of the recordings and clinical observation. RESULTS: A total of 60 patients were included, 55% of whom were hypercapnic. Auto-triggering was present in 8 (13%) patients, double triggering in 9 (15%), ineffective breaths in 8 (13%), premature cycling 7 (12%) and late cycling in 14 (23%). An AI > 10%, indicating severe asynchrony, was present in 26 patients (43%), whose median (25-75 IQR) AI was 26 (15-54%). A significant correlation was found between the magnitude of leaks and the number of ineffective breaths and severity of delayed cycling. Multivariate analysis indicated that the level of pressure support and the magnitude of leaks were weakly, albeit significantly, associated with an AI > 10%. Patient comfort scale was higher in pts with an AI < 10%. CONCLUSION: Patient-ventilator asynchrony is common in patients receiving NIV for acute respiratory failure. Our results suggest that leaks play a major role in generating patient-ventilator asynchrony and discomfort, and point the way to further research to determine if ventilator functions designed to cope with leaks can reduce asynchrony in the clinical setting.

Effects of hatching asynchrony on sibling negotiation, begging, jostling for position and within-brood food allocation in the barn owl Tyto alba

When siblings differ markedly in their need for food, they may benefit from signalling to each other their willingness to contest the next indivisible food item delivered by the parents. This sib-sib communication system, referred to as 'sibling negotiation', may allow them to adjust optimally to investment in begging. Using barn owl (Two alba) broods. I assessed the role of within-brood age hierarchy on sibling negotiation, and in turn on jostling for position where parents predictably deliver food (i.e. nest-box entrance), begging and within-brood food allocation. More specifically, I examined three predictions derived from a game-theoretical model of sibling negotiation where a senior and a junior sibling compete for food resources (Roulin, 2002a, Johnstone and Roulin, 2003): (1) begging effort invested by the senior sibling should be less sensitive to the junior sibling's negotiation than vice versa; (2) the junior should invest less effort in sibling negotiation than its senior sibling but a similar amount of effort in begging; and (3) within-brood food allocation should be directly related to begging but only indirectly to sibling negotiation. Two-chick broods were created and vocalization in the absence (negotiation signals directed to siblings) and presence (begging signals directed to parents) of parents was recorded. In support of the first prediction, juniors begged at a low cadence after their senior sibling negotiated intensely, probably because negotiation reflects prospective investment in begging and hence willingness to compete. In contrast, the begging of senior siblings was not sensitive to their junior sibling's negotiation. In contrast to the second prediction, juniors negotiated and begged more intensely than their senior sibling apparently because they were hungrier rather than younger. In line with the third prediction, juniors monopolized food delivered by their parents when their senior sibling begged at a low level. The begging cadence of both the junior and senior sibling, the junior's negotiation cadence, the difference in age between the two nest-mates and jostling for position were not associated with the likelihood of monopolizing food. In conclusion, sibling negotiation appears to influence begging behaviour, which, in turn, affects within-brood food allocation. Juniors may negotiate to challenge their senior siblings, and thereby determine whether seniors are less hungry before deciding to beg for food. In contrast, seniors may negotiate to deter juniors from begging.

Patient-ventilator asynchrony during noninvasive pressure support ventilation and neurally adjusted ventilatory assist in infants and children.

OBJECTIVES: To document the prevalence of asynchrony events during noninvasive ventilation in pressure support in infants and in children and to compare the results with neurally adjusted ventilatory assist. DESIGN: Prospective randomized cross-over study in children undergoing noninvasive ventilation. SETTING: The study was performed in a PICU. PATIENTS: From 4 weeks to 5 years. INTERVENTIONS: Two consecutive ventilation periods (pressure support and neurally adjusted ventilatory assist) were applied in random order. During pressure support (PS), three levels of expiratory trigger (ETS) setting were compared: initial ETS (PSinit), and ETS value decreased and increased by 15%. Of the three sessions, the period allowing for the lowest number of asynchrony events was defined as PSbest. Neurally adjusted ventilator assist level was adjusted to match the maximum airway pressure during PSinit. Positive end-expiratory pressure was the same during pressure support and neurally adjusted ventilator assist. Asynchrony events, trigger delay, and cycling-off delay were quantified for each period. RESULTS: Six infants and children were studied. Trigger delay was lower with neurally adjusted ventilator assist versus PSinit and PSbest (61 ms [56-79] vs 149 ms [134-180] and 146 ms [101-162]; p = 0.001 and 0.02, respectively). Inspiratory time in excess showed a trend to be shorter during pressure support versus neurally adjusted ventilator assist. Main asynchrony events during PSinit were autotriggering (4.8/min [1.7-12]), ineffective efforts (9.9/min [1.7-18]), and premature cycling (6.3/min [3.2-18.7]). Premature cycling (3.4/min [1.1-7.7]) was less frequent during PSbest versus PSinit (p = 0.059). The asynchrony index was significantly lower during PSbest versus PSinit (40% [28-65] vs 65.5% [42-76], p < 0.001). With neurally adjusted ventilator assist, all types of asynchronies except double triggering were reduced. The asynchrony index was lower with neurally adjusted ventilator assist (2.3% [0.7-5] vs PSinit and PSbest, p < 0.05 for both comparisons). CONCLUSION: Asynchrony events are frequent during noninvasive ventilation with pressure support in infants and in children despite adjusting the cycling-off criterion. Compared with pressure support, neurally adjusted ventilator assist allows improving patient-ventilator synchrony by reducing trigger delay and the number of asynchrony events. Further studies should determine the clinical impact of these findings.

Automated detection of patient-ventilator asynchrony: new tool or new toy?

Although severe patient-ventilator asynchrony is frequent during invasive and non-invasive mechanical ventilation, diagnosing such asynchronies usually requires the presence at the bedside of an experienced clinician to assess the tracings displayed on the ventilator screen, thus explaining why evaluating patient-ventilator interaction remains a challenge in daily clinical practice. In the previous issue of Critical Care, Sinderby and colleagues present a new automated method to detect, quantify, and display patient-ventilator interaction. In this validation study, the automatic method is as efficient as experts in mechanical ventilation. This promising system could help clinicians extend their knowledge about patient-ventilator interaction and further improve assisted mechanical ventilation.

Land use imperils plant and animal community stability through changes in asynchrony rather than diversity

Human land use may detrimentally affect biodiversity, yet long-term stability of species communities is vital for maintaining ecosystem functioning. Community stability can be achieved by higher species diversity (portfolio effect), higher asynchrony across species (insurance hypothesis) and higher abundance of populations. However, the relative importance of these stabilizing pathways and whether they interact with land use in real-world ecosystems is unknown. We monitored inter-annual fluctuations of 2,671 plant, arthropod, bird and bat species in 300 sites from three regions. Arthropods show 2.0-fold and birds 3.7-fold higher community fluctuations in grasslands than in forests, suggesting a negative impact of forest conversion. Land-use intensity in forests has a negative net impact on stability of bats and in grasslands on birds. Our findings demonstrate that asynchrony across species—much more than species diversity alone—is the main driver of variation in stability across sites and requires more attention in sustainable management.

Effects of reflex stimulus intensity and stimulus onset asynchrony on prepulse inhibition and perceived intensity of the blink-eliciting stimulus

Prepulse inhibition of the blink reflex is widely applied to investigate information processing deficits in schizophrenia and other psychiatric patient groups. The present experiment investigated the hypothesis that prepulse inhibition reflects a transient process that protects preattentive processing of the prepulse. Participants were presented with pairs of blinkeliciting noises, some preceded by a prepulse at a variable stimulus onset asynchrony (SOA), and were asked to rate the intensity of the second noise relative to the first. Inhibition of blink amplitude was greater for a 110-dB (A) noise than for a 95-dB(A) noise with a 120-ms SOA, whereas there was no difference with a 30-ms SOA. The perceived intensity was also lower for the 110-dB(A) noise than for the 95-dB(A) noise with the 120-ms SOA, but not with the 30-ms SOA. The parallel results support a relationship between prepulse inhibition of response amplitude and perceived intensity. However, the prepulse did not reduce intensity ratings relative to control trials in some conditions, suggesting that prepulse inhibition is not always associated with an attenuation of the perceived impact of the blink-eliciting stimulus.

Wideband inhibition modulates the effect of onset asynchrony as a grouping cue

Onset asynchrony is arguably the most powerful grouping cue for the separation of temporally overlapping sounds (see Bregman 1990). A component that begins only 30–50 ms before the others makes a greatly reduced contribution to the timbre of a complex tone, or to the phonetic quality of a vowel (e.g. Darwin 1984). This effect of onset asynchrony does not necessarily imply a cognitive grouping process; instead it may result from peripheral adaptation in the response to the leading component in the few tens of milliseconds before the other components begin (e.g., Westerman and Smith 1984). However, two findings suggest that the effect of onset asynchrony cannot be explained entirely by peripheral adaptation. First, though the effect is smaller, the contribution of a component to the phonetic quality of a short-duration vowel is reduced when it ends after the other components (Darwin and Sutherland 1984; Roberts and Moore 1991).

Contralateral influences of wideband inhibition on the effect of onset asynchrony as a cue for auditory grouping

Onset asynchrony is an important cue for segregating sound mixtures. A harmonic of a vowel that begins before the other components contributes less to vowel quality. This asynchrony effect can be partly reversed by accompanying the leading portion of the harmonic with an octave-higher captor tone. The original interpretation was that the captor and leading portion formed a perceptual group, but it has recently been shown that the captor effect depends on neither a common onset time nor harmonic relations with the leading portion. Instead, it has been proposed that the captor effect depends on wideband inhibition in the central auditory system. Physiological evidence suggests that such inhibition occurs both within and across ears. Experiment 1 compared the efficacy of a pure-tone captor presented in the same or opposite ear to the vowel and leading harmonic. Contralateral presentation was at least as effective as ipsilateral presentation. Experiment 2 used multicomponent captors in a more comprehensive evaluation of harmonic influences on captor efficacy. Three captors with different fundamental frequencies were used, one of which formed a consecutive harmonic series with the leading harmonic. All captors were equally effective, irrespective of the harmonic relationship. These findings support and refine the inhibitory account. © 2007 Acoustical Society of America.

Inhibitory influences on asynchrony as a cue for auditory segregation

A harmonic that begins before the other harmonics contributes less than they do to vowel quality. This reduction can be partly reversed by accompanying the leading portion with a captor tone. This effect is usually interpreted as reflecting perceptual grouping of the captor with the leading portion. Instead, it has recently been proposed that the captor effect depends on broadband inhibition within the central auditory system. A test of psychophysical predictions based on this proposal showed that captor efficacy is (a) maintained for noise-band captors, (b) absent when a captor accompanies a harmonic that continues after the vowel, and (c) maintained for 80 ms or more over a gap between captor offset and vowel onset. These findings support and refine the inhibitory account. PsycINFO Database Record © 2006 APA, all rights reserved.

Asynchrony and the grouping of vowel components:captor tones revisited

Asynchrony is an important grouping cue for separating sound mixtures. A harmonic incremented in level makes a reduced contribution to vowel timbre when it begins before the other components. This contribution can be partly restored by adding a captor tone in synchrony with, and one octave above, the leading portion of the incremented harmonic [Darwin and Sutherland, Q. J. Exp. Psychol. A 36, 193-208 (1984)]. The captor is too remote to evoke adaptation in peripheral channels tuned to the incremented harmonic, and so the restoration effect is usually attributed to the grouping of the leading portion with the captor. However, results are presented that contradict this interpretation. Captor efficacy does not depend on a common onset, or harmonic relations, with the leading component. Rather, captor efficacy is influenced by frequency separation, and extends to about 1.5 oct above the leading component. Below this cutoff, the captor effect is equivalent to attenuating the leading portion of the incremented harmonic by about 6 dB. These results indicate that high-level grouping does not govern the captor effect. Instead, it is proposed that the partial restoration of the contribution of an asynchronous component to vowel timbre depends on broadband inhibition within the central auditory system. © 2006 Acoustical Society of America.

The influence of adaptation and inhibition on the effects of onset asynchrony on auditory grouping

Onset asynchrony is an important cue for auditory scene analysis. For example, a harmonic of a vowel that begins before the other components contributes less to the perceived phonetic quality. This effect was thought primarily to involve high-level grouping processes, because the contribution can be partly restored by accompanying the leading portion of the harmonic (precursor) with a synchronous captor tone an octave higher, and hence too remote to influence adaptation of the auditory-nerve response to that harmonic. However, recent work suggests that this restoration effect arises instead from inhibitory interactions relatively early in central auditory processing. The experiments reported here have reevaluated the role of adaptation in grouping by onset asynchrony and explored further the inhibitory account of the restoration effect. Varying the frequency of the precursor in the range ± 10% relative to the vowel harmonic (Experiment 1), or introducing a silent interval from 0 to 320 ms between the precursor and the vowel (Experiment 2), both produce effects on vowel quality consistent with those predicted from peripheral adaptation or recovery from it. However, there were some listeners for whom even the smallest gap largely eliminated the effect of the precursor. Consistent with the inhibitory account of the restoration effect, a contralateral pure tone whose frequency is close to that of the precursor is highly effective at restoring the contribution of the asynchronous harmonic (Experiment 3). When the frequencies match, lateralization cues arising from binaural fusion of the precursor and contralateral tone may also contribute to this restoration. (PsycINFO Database Record (c) 2012 APA, all rights reserved)