Model-based estimation of negative inspiratory driving pressure in patients receiving invasive NAVA mechanical ventilation

Abstract

BackgroundOptimisation of mechanical ventilation (MV) and weaning requires insight into underlying patient breathing effort. Current identifiable models effectively describe lung mechanics, such as elastance (E) and resistance (R) at the bedside in sedated patients, but are less effective when spontaneous breathing is present. This research derives and regularises a single compartment model to identify patient-specific inspiratory effort. MethodsConstrained second-order b-spline basis functions (knot width 0.05 s) are used to describe negative inspiratory drive (Pp, cmH2O) as a function of time. Breath-breath Pp are identified with single E and R values over inspiration and expiration from n = 20 breaths for N = 22 patients on NAVA ventilation. Pp is compared to measured electrical activity of the diaphragm (Eadi) and published results. ResultsAverage per-patient root-mean-squared model fit error was (median [interquartile range, IQR]) 0.9 [0.6–1.3] cmH2O, and average per-patient median Pp was -3.9 [-4.5– -3.0] cmH2O, with range -7.9 – -1.9 cmH2O. Per-patient E and R were 16.4 [13.6–21.8] cmH2O/L and 9.2 [6.4–13.1] cmH2O.s/L, respectively. Most patients showed an inspiratory volume threshold beyond which Pp started to return to baseline, and Pp at peak Eadi (end-inspiration) was often strongly correlated with peak Eadi (R2=0.25–0.86). Similarly, average transpulmonary pressure was consistent breath-breath in most patients, despite differences in peak Eadi and thus peak airway pressure. ConclusionsThe model-based inspiratory effort aligns with electrical muscle activity and published studies showing neuro-muscular decoupling as a function of pressure and/or volume. Consistency in coupling/dynamics were patient-specific. Quantification of patient and ventilator work of breathing contributions may aid optimisation of MV modes and weaning.