IntelliSync+

Keeping an eye on patient-ventilator synchrony

Based on feedback from clinicians,
optimal patient-ventilator synchronisation
is becoming a relevant clinical topic.
Number of studies published on this topic

Garofalo E, et al. Expert Rev Respir Med. 2018 Jul;12(7):557-567

Clinical findings

Prevalence Prolonged mechanical ventilation

• Significant patient-ventilator • With high Asynchrony Index (AI)
asynchrony in 40% of patients 7 vs 25 days
• Number of tracheostomies 4 vs 33%

Increased WOB Associated with higher mortality

• In COPD patients proper adjustment of • When AI > 10 % as compared to
ETS reduces WOB, PEEPi, number of AI < 10 %
delayed cyclings and ineffective efforts
Tassaux D, Am J Respir Crit Care Med. 2005 ¦ Thille AW, Intensive Care Med. 2006 ¦ Blanche Intensive Care Med. 2015
How to detect asynchronies?
How to detect asynchronies?

What does optimal synchrony look like?

The expert method
Waveform analysis

22
beginning 22
end
20 of the patient’s 20 of the patient’s
18 inspiration 18 inspiration

Paw [cmH2O]

Paw [cmH2O]
deflection 16
14
16
14
on the pressure curve 12 12
10 10
8 8
6 6

600 600

400 400

200 200
Flow [mL/s]

Flow [mL/s]
0 0

-200 -200

-400 -400
deflection -600 -600
on the flow curve -800 -800

Mojoli F, et al. Intensive Care Med (2016) 42:914–915

 22
beginning 22
end
20 of the patient’s 20 of the patient’s
18 inspiration 18 inspiration

Paw [cmH2O]

Paw [cmH2O]
16 16
14 14
12 12
10 10

Waveform
8 8
6 6

analysis
600 600

400 400

200 200

Flow [mL/s]

Flow [mL/s]
0 0

-200 -200

-400 -400

-600 -600

-800 -800

2 2
‘half-
0 0 relaxation’
Pmus [cmH2O]

Pmus [cmH2O]
-2 -2

-4 -4

-6 -6

Mojoli F, et al. Intensive Care Med (2016) 42:914–915

How to detect asynchronies?

Classifications
Patient-Ventilator interaction – phase variables

A complete ventilatory cycle or breath

consists of four phases:

1. The initiation of inspiration

2. Inspiration itself
3. The end of inspiration
4. Expiration

Modified from: MacIntyre N, Chest 1990; 97(6):1463–1466.

How can we classify asynchronies?

1 2
PHASE ASYNCHRONIES FLOW ASYNCHRONIES
ASYNCHRONIES related to ASYNCHRONIES related to
TRIGGERING and CYCLING THE LEVEL of ASSIST

Neural breath is not in phase with Assist that the ventilator provides does
mechanical breath. not match the actual need of the patient.
Phase asynchronies
Asynchronies related to triggering and cycling

22

… the initiation of inspiration 20

18
… the end of inspiration

Paw [cmH2O]
16

TRIGGER asynchronies 14 CYCLING asynchronies

12

• Auto trigger 10
8
• Early cycling
• Delayed trigger • Double triggering
6

600

• Ineffective effort • Late cycling

400

200
Flow [mL/s]

0
• Reverse triggering -200

-400

-600

-800
Flow asynchronies
Asynchronies related to the level of assist

22
20
18

Paw [cmH2O]
16
14
12

Insufficient assistance 10
8
Over assistance
• Flow starvation • Flow overshoot
6

600

• Insufficient flow
400

200
Flow [mL/s]

-200

-400

-600

-800
How to detect asynchronies?

Forms of asynchrony
 Auto-triggered Patient-triggered

Auto trigger 30
breath breath

25

Paw [cmH2O]
20

Ventilator is triggered in the absence of

15

patient effort.
10

1. Absence of - deflection in Paw

2. Presence of zero flow before the
1500

mechanical breath

Flow [mL/s]
1000

3. Different flow-time profile of the auto- 500

triggered breath 0

-500

-1000

-1500
 30

Delayed trigger 25

Paw [cmH2O]
20

15

Increased time interval between: 10

The patient effort (– deflection in Paw and 1500

+ deflection in Flow) and

1000

The beginning of mechanical insufflation.

500

Flow [mL/s]
0

-500

-1000

-1500
 35

Ineffective effort 30

Paw [cmH2O]
25

20

Patient efforts that fail to trigger the 15 1

ventilator. 10

1250

1. Presence of distortion in the Paw waveform 1000

2. Abrupt change in Flow waveform 750

2
500
(decrease in expiratory flow or increase in inspiratory flow)

Flow [mL/s]
250

3. NO ventilator assistance follows 0

-250

-500

-750 3
-1000
 24

Early cycling
22

20

Paw [cmH2O]
18

16

Mechanical inspiration is shorter than 14

neural inspiration. 12

800

1. Abrupt decrease in Paw (to 0 or PEEP level)

600

400

2. “Small bump” at the beginning of

Flow [mL/s]
200

expiration (after PEF) 0

-200

-400

-600

-800
Reverse triggering

Flow [L/s]
0,8

Muscle efforts resulting from

mechanical inflation. 20

Paw [cmH2O]
10

1. An increase in expiratory flow or

0
2. Decrease in inspiratory Paw later in the
respiratory cycle can indicate the event. 10

Pes [cmH2O]
5

Akoumianaki E, et al. CHEST 2013; 143(4):927–938

 20
Forms of asynchrony:
Double triggering 15

Paw [cmH2O]
10

Delivery of two (or more) ventilator 0

insufflations during one single

inspiratory effort.
100

75

1. Two consecutively triggered breaths

separated by a very short expiratory time

Flow [L/min]
50

(< 50% of the mean inspiratory time)

25
2. Second breath is rather short in most cases
0

-25
Double-triggering
and delivered VT

Double-trigger Vt

Normal trigger Vt

Robinson BR, et al. Respir Care 2013;58(11):1847–1855.

Delayed cycling
30

25

Mechanical inspiration extends into

Paw [cmH2O]
20

neural expiration. 15

10

1. Fast decrease in inspiratory flow followed

by an exponential decline
2. Abrupt increase in Paw near the end of
1500

1000

inspiration

Flow [mL/s]
500

-500

-1000

-1500

* Sign of inspiratory muscle relaxation or expiratory muscle contraction

Associated asynchronies

Kondili E, et al. Br J Anaesth 2003; 91: 106±19

Can you recognize this phase asynchrony?

A) Auto-triggering
B) Double triggering
C) Delayed cycling
D) Late cycling
E) None of these
Can you recognize this phase asynchrony?

A) Ineffective effort
B) Premature cycling
C) Double triggering
D) Auto-triggering
E) None of these
Can you recognize this phase asynchrony?

A) Double triggering
B) Ineffective effort
C) Delayed cycling
D) Auto-triggering
E) None of these
Can you recognize this phase asynchrony?

A) Double triggering
B) Ineffective effort
C) Premature cycling
D) Auto-triggering
E) No asynchrony
Our current methods for optimizing
phase synchrony
Leak compensation with IntelliTrig
Flow and Pressure trigger sensitivity
ETS – Expiratory trigger sensitivity
Maximum flow = 100%

ETS = 25% of
maximum flow
The problem with “fixed” settings
Fixed inspiratory trigger
Fixed expiratory trigger
Flow
l/min
Late cycling Late cycling
50

25

-25

Increased work of breathing

-50 Increased patient discomfort
Ineffective effort
What other methods are there
for optimizing phase synchrony?
We need a more sensible
solution
Easy to use
Noninvasive method
Recognize beginning of inspiration
and expiration
No sensors or additional hardware
For all ventilation modes
For adult and pediatric patients
Then you need to know what to do . . .

Subira` C, et al. Respir Care. 2018 Apr;63(4):464-478.

NOT so simple!
Problem with the expert method

Expert is not always at bedside

Trigger often remain unchanged
when ventilation settings are
adjusted
Constantly changing patient
conditions and leaks
Real-time in-breath optimization is
impossible to achieve
. . . we had something different in mind!
We had in mind . . .

A patient
Who is ventilated, receiving 20-35,000 breaths/day. We know that clinicians
cannot always be there to adapt settings when the patient’s condition changes.
We wanted to keep an eye on every single breath!

Who might need ventilatory support for just a few hours.

We didn’t want an “additional cost” for every treatment to be the reason for
not providing the best level of care!
We had in mind . . .

A physician:
In a situation where it is difficult to recognize that the problem (asynchrony)
exists, or
Having difficulty finding the right triggering or cycling criteria for his patient.

We wanted every single breath to start and end with the patient and ventilator
in perfect synchrony . . .
. . . regardless of the mode the physician decides to use!
We had in mind .the
. . expert eye
IntelliSync+
Implementing the «expert eye»
in the ventilator
Implementing the «expert eye»

Continuous waveform analysis 24/7

Automatic recognition of inspiratory
efforts and optimal cycling points
Automation of either inspiratory
trigger or expiratory trigger, or both
How IntelliSync+ works

Mimics the expert‘s eye to identify signs

of patient effort (trigger) or relaxation
(cycling)
Continuously analyzes waveform shapes
hundreds of times per second
Real-time, in-breath adaptation to
changing patient conditions and leaks
Patient can trigger even when
flow is still negative
expiration is incomplete
Next step in synchronization by Hamilton Medical
Next step in synchronization by Hamilton Medical
With conventional triggers

Same situation with IntelliSync+

IntelliSync+

Synchronization during inspiration

and expiration
With all invasive or noninvasive
ventilation modes
Noninvasive method
Requires no additional hardware or
consumables
Made possible by…
IntelliSync+
Limiting factors
• Cardiac oscillations
• Accumulation of condensate
disturbing the flow sensor
• Reverse triggering
• Flow asynchronies
Thank you very much for your attention!
Hamilton Medical clinical group
Thomas Reimer

Hamilton Medical AG
Via Crusch 8, 7402 Bonaduz, Switzerland
( +41 58 610 10 20
info@hamilton-medical.com
www.hamilton-medical.com