Non-invasive assessment of respiratory muscle activity during pressure support ventilation: accuracy of end-inspiration occlusion and least square fitting methods

Abstract

Pressure support ventilation (PSV) should be titrated considering the pressure developed by the respiratory muscles (P_musc) to prevent under- and over-assistance. The esophageal pressure (P_es) is the clinical gold standard for P_musc assessment, but its use is limited by alleged invasiveness and complexity. The least square fitting method and the end-inspiratory occlusion method have been proposed as non-invasive alternatives for P_musc assessment. The aims of this study were: (1) to compare the accuracy of P_musc estimation using the end-inspiration occlusion (P_musc,index) and the least square fitting (P_musc,lsf) against the reference method based on P_es; (2) to test the accuracy of P_musc,lsf and of P_musc,index to detect overassistance, defined as P_musc ≤ 1 cmH₂O. We studied 18 patients at three different PSV levels. At each PSV level, P_musc, P_musc,lsf, P_musc,index were calculated on the same breaths. Differences among P_musc, P_musc,lsf, P_musc,index were analyzed with linear mixed effects models. Bias and agreement were assessed by Bland-Altman analysis for repeated measures. The ability of P_musc,lsf and P_musc,index to detect overassistance was assessed by the area under the receiver operating characteristics curve. Positive and negative predictive values were calculated using cutoff values that maximized the sum of sensitivity and specificity. At each PSV level, P_musc,lsf was not different from P_musc (p = 0.96), whereas P_musc,index was significantly lower than P_musc. The bias between P_musc and P_musc,lsf was zero, whereas P_musc,index systematically underestimated P_musc of 6 cmH₂O. The limits of agreement between P_musc and P_musc,lsf and between P_musc and P_musc,index were ± 12 cmH₂O across bias. Both P_musc,lsf ≤ 4 cmH₂O and P_musc,index ≤ 1 cmH₂O had excellent negative predictive value [0.98 (95% CI 0.94-1) and 0.96 (95% CI 0.91-0.99), respectively)] to identify over-assistance. The inspiratory effort during PSV could not be accurately estimated by the least square fitting or end-inspiratory occlusion method because the limits of agreement were far above the signal size. These non-invasive approaches, however, could be used to screen patients at risk for absent or minimal respiratory muscles activation to prevent the ventilator-induced diaphragmatic dysfunction.

Keywords: End-inspiratory occlusion; Esophageal pressure; Inspiratory effort; Least square fitting; Mechanical ventilation; Respiratory muscles.