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Background: We aimed (1) to describe the characteristics of patient-ventilator asynchrony in a population of critically ill children, (2) to describe the risk factors associated with patient-ventilator asynchrony, and (3) to evaluate the association between patient-ventilator asynchrony and ventilator-free days at day 28.

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Methods:

In this single-center prospective study, consecutive children admitted to the PICU and mechanically ventilated for at least 24 h were included. Patient-ventilator asynchrony was analyzed by comparing the ventilator pressure curve and the electrical activity of the diaphragm (Edi) signal with (1) a manual analysis and (2) using a standardized fully automated method.

Results: Fifty-two patients (median age 6 months) were included in the analysis. Eighteen patients had a very low ventilatory drive (i.e., peak Edi < 2 µV on average), which prevented the calculation of patient-ventilator asynchrony. Children spent 27% (interquartile 22-39%) of the time in conflict with the ventilator. Cycling-off errors and trigger delays contributed to most of this asynchronous time. The automatic algorithm provided a NeuroSync index of 45%, confirming the high prevalence of asynchrony. No association between the severity of asynchrony and ventilator-free days at day 28 or any other clinical secondary outcomes was observed, but the proportion of children with good synchrony was very low.

Conclusion: Patient-ventilator interaction is poor in children supported by conventional ventilation, with a high frequency of depressed ventilatory drive and a large proportion of time spent in asynchrony. The clinical benefit of strategies to improve patient-ventilator interactions should be evaluated in pediatric critical care. which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

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Results
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Outcome

We did not observe any association between the level of asynchrony and neither ventilator-free days at day 28, nor the secondary outcomes (Table 2). This holds true with the manual classification as severe PVA or not (Table 2), as well as with the automated NeuroSync index (correlation with ventilation duration: R 2 = 0.12; p = 0.58). None of the patient characteristics were associated with the duration of mechanical ventilation.

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Conclusion

Patient-ventilator interaction is poor in critically ill children supported by conventional ventilation. The study did not permit to ascertain if these poor interactions have important clinical consequence. But the magnitude of PVA and the prevalence of low ventilatory drive warrant further studies to assess whether strategies to optimize patient-ventilator interactions can improve the outcome of PICU patients. Fig. 4 Relationship between the asynchrony results obtained using the two methods: the automatic NeuroSync index and the percentage of time spent in asynchrony derived from the manual breath-bybreath analysis

Fig. 1Study flowchart (*patients could be excluded for two reasons)
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1 Characteristics of population (n = 52) Data are expressed as median (interquartile range) or n (%) Edi electrical activity of the diaphragm, MV mechanical ventilation, PICU pediatric intensive care unit, PEEP positive end-expiratory pressure *Significant difference between the two groups (
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Fig. 2Contribution of the different types of asynchrony in the total time spent in conflict with the ventilator
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Fig. 3Evolution of inspiratory Edi (panel a) and of the time spent in asynchrony (panel b) from inclusion time (time 1) to pre-extubation period (time 2)
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Table
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Table 2Characteristics of patients depending on the level of asynchrony (in patients with Edi > 2 µV, n = 34)\n
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Table 2 continued% time spent in asynchrony < 39% (n = 25) % time spent in asynchrony > 39% (n = 9) p value\n\n
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Acknowledgements

The authors are indebted to the patients and their families for their willingness to participate in our study. We thank Mariana Dumitrascu, Laurence Bertout, and Noémie Loron for their help in the screening and enrollment process, Lucy Clayton for the study management support, the respiratory therapists for their logistic help, the PICU fellows, attending healthcare providers, and PICU nurses for their collaboration, and Norman Comtois for his invaluable support regarding signal recording and analysis. This work was performed in CHU Sainte-Justine, Pediatric Intensive Care Unit, Montreal, Quebec, Canada.

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Abbreviations

Edi: electrical activity of the diaphragm; ETT: endotracheal tube; NAVA: neurally adjusted ventilatory assist; PICU: pediatric intensive care unit; PSV: pressure support ventilation; PVA: patient-ventilator asynchrony.

Authors' contributions AL, GE, OF, SE, and PJ designed the study. GM, AL, GC, AAPL, OF, JB, CS, and GE performed the analysis and carried out the chart review and data collection. GM, JB, CS, PJ, and GE wrote the manuscript, which was reviewed, edited, and approved by all authors. As the corresponding author, GE has full access to all the data in the study and has final responsibility for the decision to submit for publication. All authors read and approved the final manuscript. 1 Pediatric Intensive Care Unit, CHU Sainte-Justine, 3175 Côte Sainte-Catherine,

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Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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\n\n\t\t\t\t\n\n\n\t\n\t\tRisk factors associated with increased length of mechanical ventilation in children\n\t\t\n\t\t\tVPayen\n\t\t\n\t\t\n\t\t\tPJouvet\n\t\t\n\t\t\n\t\t\tJLacroix\n\t\t\n\t\t\n\t\t\tTDucruet\n\t\t\n\t\t\n\t\t\tFGauvin\n\t\t\n\t\n\t\n\t\tPediatr Crit Care Med\n\t\t\n\t\t\t13\n\t\t\t2\n\t\t\t\n\t\t\t\n\t\t\n\t\n\tPayen V, Jouvet P, Lacroix J, Ducruet T, Gauvin F. Risk factors associated with increased length of mechanical ventilation in children. Pediatr Crit Care Med. 2012;13(2):152-7.\n\n\n\n\t\n\t\tVentilator-induced diaphragmatic dysfunction: what have we learned?\n\t\t\n\t\t\tBJPetrof\n\t\t\n\t\t\n\t\t\tSNHussain\n\t\t\n\t\n\t\n\t\tCurr Opin Crit Care\n\t\t\n\t\t\t22\n\t\t\t1\n\t\t\t\n\t\t\t\n\t\t\n\t\n\tPetrof BJ, Hussain SN. Ventilator-induced diaphragmatic dysfunction: what have we learned? Curr Opin Crit Care. 2016;22(1):67-72.\n\n\n\n\t\n\t\tPatient-ventilator interaction during neurally adjusted ventilatory assist in low birth weight infants\n\t\t\n\t\t\tJBeck\n\t\t\n\t\t\n\t\t\tMReilly\n\t\t\n\t\t\n\t\t\tGGrasselli\n\t\t\n\t\t\n\t\t\tLMirabella\n\t\t\n\t\t\n\t\t\tASSlutsky\n\t\t\n\t\t\n\t\t\tMSDunn\n\t\t\n\t\n\t\n\t\tPediatr Res\n\t\t\n\t\t\t65\n\t\t\t6\n\t\t\t\n\t\t\t\n\t\t\n\t\n\tBeck J, Reilly M, Grasselli G, Mirabella L, Slutsky AS, Dunn MS, et al. Patient-ventilator interaction during neurally adjusted ventilatory assist in low birth weight infants. Pediatr Res. 2009;65(6):663-8.\n\n\n\n\t\n\t\tNeurally adjusted ventilatory assist as an alternative to pressure support ventilation in adults: a French multicentre randomized trial\n\t\t\n\t\t\tADemoule\n\t\t\n\t\t\n\t\t\tMClavel\n\t\t\n\t\t\n\t\t\tCRolland-Debord\n\t\t\n\t\t\n\t\t\tSPerbet\n\t\t\n\t\t\n\t\t\tNTerzi\n\t\t\n\t\t\n\t\t\tAKouatchet\n\t\t\n\t\n\t\n\t\tIntensive Care Med\n\t\t\n\t\t\t42\n\t\t\t11\n\t\t\t\n\t\t\t\n\t\t\n\t\n\tDemoule A, Clavel M, Rolland-Debord C, Perbet S, Terzi N, Kouatchet A, et al. Neurally adjusted ventilatory assist as an alternative to pressure sup- port ventilation in adults: a French multicentre randomized trial. Intensive Care Med. 2016;42(11):1723-32.\n\n\n\t\t\t\t\n\t\t\t
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