Automated detection and quantification of reverse triggering effort under mechanical ventilation

Crit Care. 2021 Feb 15;25(1):60. doi: 10.1186/s13054-020-03387-3.


Background: Reverse triggering (RT) is a dyssynchrony defined by a respiratory muscle contraction following a passive mechanical insufflation. It is potentially harmful for the lung and the diaphragm, but its detection is challenging. Magnitude of effort generated by RT is currently unknown. Our objective was to validate supervised methods for automatic detection of RT using only airway pressure (Paw) and flow. A secondary objective was to describe the magnitude of the efforts generated during RT.

Methods: We developed algorithms for detection of RT using Paw and flow waveforms. Experts having Paw, flow and esophageal pressure (Pes) assessed automatic detection accuracy by comparison against visual assessment. Muscular pressure (Pmus) was measured from Pes during RT, triggered breaths and ineffective efforts.

Results: Tracings from 20 hypoxemic patients were used (mean age 65 ± 12 years, 65% male, ICU survival 75%). RT was present in 24% of the breaths ranging from 0 (patients paralyzed or in pressure support ventilation) to 93.3%. Automatic detection accuracy was 95.5%: sensitivity 83.1%, specificity 99.4%, positive predictive value 97.6%, negative predictive value 95.0% and kappa index of 0.87. Pmus of RT ranged from 1.3 to 36.8 cmH20, with a median of 8.7 cmH20. RT with breath stacking had the highest levels of Pmus, and RTs with no breath stacking were of similar magnitude than pressure support breaths.

Conclusion: An automated detection tool using airway pressure and flow can diagnose reverse triggering with excellent accuracy. RT generates a median Pmus of 9 cmH2O with important variability between and within patients.

Trial registration: BEARDS, NCT03447288.

Keywords: Dyssynchrony; Lung and diaphragm protection; Mechanical ventilation; Respiratory muscles; Reverse triggering.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Area Under Curve
  • Female
  • Humans
  • Male
  • Middle Aged
  • Positive-Pressure Respiration / methods
  • Positive-Pressure Respiration / statistics & numerical data
  • Pressure
  • ROC Curve
  • Respiration, Artificial / methods*
  • Respiration, Artificial / statistics & numerical data
  • Respiratory Mechanics / physiology
  • Weights and Measures / instrumentation
  • Work of Breathing / physiology*

Associated data