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Vol. 47. Issue 11.
Pages 648-657 (November 2023)
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Vol. 47. Issue 11.
Pages 648-657 (November 2023)
Review article
Reverse triggering during mechanical ventilation: Diagnosis and clinical implications
Trigger reverso durante ventilación mecánica: diagnóstico e implicancias clínicas
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Juan M. Núñez Silveiraa, Adrián Gallardob, Patricio García-Valdésc,d, Fernando Ríose, Pablo O. Rodriguezf,g, L. Felipe Damianic,d,
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Lfdamiani@uc.cl

Corresponding author.
a Servicio de Kinesiología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
b Servicio de Kinesiología, Sanatorio Clínica Modelo de Morón, Morón, Buenos Aires, Argentina
c Departamento de Ciencias de la Salud, Carrera de Kinesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
d CardioREspirAtory Research Laboratory (CREAR), Pontificia Universidad Católica de Chile, Santiago, Chile
e Casa Hospital San Juan De Dios, Ramos Mejía, Buenos Aires, Argentina
f Unidad de Terapia Intensiva, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
g Instituto Universitario CEMIC (IUC), Buenos Aires, Argentina
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Table 1. Principal reverse triggering detection methods.
Table 2. Unresolved issues in reverse triggering.
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Abstract

This review addresses the phenomenon of "reverse triggering", an asynchrony that occurs in deeply sedated patients or patients in transition from deep to light sedation. Reverse triggering has been reported to occur in 30–90% of all ventilated patients. The underlying pathophysiological mechanisms remain unclear, but “entrainment” is proposed as one of them. Detecting this asynchrony is crucial, and methods such as visual inspection, esophageal pressure, diaphragmatic ultrasound and automated methods have been used. Reverse triggering may have effects on lung and diaphragm function, probably mediated by the level of breathing effort and eccentric activation of the diaphragm. The optimal management of reverse triggering has not been established, but may include the adjustment of ventilatory parameters as well as of sedation level, and in extreme cases, neuromuscular block. It is important to understand the significance of this condition and its detection, but also to conduct dedicated research to improve its clinical management and potential effects in critically ill patients.

Keywords:
Reverse triggering
Mechanical ventilation
Patient-ventilator asynchrony
Resumen

Esta revisión aborda el fenómeno "trigger reverso", una asincronía que se presenta en pacientes sedados o en transición de despertar, con una prevalencia en estos grupos del 30% al 90%. Los mecanismos fisiopatológicos aún no están claros, pero se propone el "entrainment" como uno de ellos. Detectar esta asincronía es complejo y se han usado métodos como inspección visual, presión esofágica, ecografía diafragmática y métodos automáticos. El trigger reverso puede tener efectos en la función pulmonar y diafragmática, mediados porbablemente por el nivel de esfuerzo respiratorio y la activación excéntrica del diafragma.El manejo óptimo no está establecido y puede incluir ajuste de parámetros ventilatorios, frecuencia respiratoria, nivel de sedación y en casos extremos, bloqueo neuromuscular. Es importante comprender su significancia, su detección e incrementar la investigación para mejorar su manejo clínico y sus potenciales efectos en los pacientes críticamente enfermos.

Palabras clave:
Trigger reverso
Ventilación mecánica
Asincronía paciente-ventilador

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