Program Description
Reverse triggering dyssynchrony is a frequent phenomenon recently recognized in sedated critically ill patients under controlled ventilation. It occurs in at least 30–55% of these patients and often occurs in the transition from fully passive to assisted mechanical ventilation.
During reverse triggering, patient inspiratory efforts start after the passive insufflation by mechanical breaths. The most often referred mechanism is the entrainment of the patient's intrinsic respiratory rhythm from the brainstem respiratory centers to periodic mechanical insufflations from the ventilator. However, reverse triggering might also occur because of local reflexes without involving the respiratory rhythm generator in the brainstem.
Reverse triggering is observed during the acute phase of the disease, when patients may be susceptible to potential deleterious consequences of injurious or asynchronous efforts. Diagnosing reverse triggering might be challenging and can easily be missed. Inspection of ventilator waveforms or more sophisticated methods, such as the electrical activity of the diaphragm or esophageal pressure, can be used for diagnosis. The occurrence of reverse triggering might have clinical consequences. On the basis of physiological data, reverse triggering might be beneficial or injurious for the diaphragm and the lung, depending on the magnitude of the inspiratory effort.
Reverse triggering can cause breath-stacking and loss of protective lung ventilation when triggering a second cycle. Little is known about how to manage patients with reverse triggering; however, available evidence can guide management on the basis of physiological principles.
Target Audience
Pulmonologists, critical care specialists, translational researchers, and clinicians
Learning Objectives
After reading this journal article, learners will be able to:
- Identify signals of reverse triggering in patients under controlled ventilation.
- Detect and quantify the intrinsic respiratory rate of a patient with reverse triggering under controlled ventilation and describe how this information can support clinical decision-making.
- Identify potentially favorable or harmful effects of reverse triggering in patients under controlled ventilation.
Course summary
1.00 Participation
1.00 AMA PRA Category 1 Credit
Credit Expires: February 28, 2025
Format: Journal
ACCREDITATION STATEMENT
The American Thoracic Society is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
| Credit Type | Credit/Points | Credit Designation Statement |
| AMA PRA Category 1 Credit™ | 1.00 | The American Thoracic Society designates this Journal for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. |
DISCLOSURE DECLARATIONS
Disclosure Declaration
The current practice of the American Journal of Respiratory and Critical Care Medicine (AJRCCM) is to publish high quality, peer-reviewed and evidence-based original research, Concise Clinical Reviews, Guidelines and Consensus Statements. Articles published in AJRCCM include evidence-based summaries of optimal practice (Concise Clinical Reviews), evidence-based guidelines, workshop summaries and original contributions that will influence clinical practice. The publication of these articles by itself is only one piece of a multi-step process for the translation of evidence-based improvements in care to clinical practice. Articles selected for CME credit are designed to be the next step in the process of translating clinically relevant, evidence-based recommendations into clinical practice. This will be accomplished through a series of questions specifically designed by the author(s) to test that readers have the tools needed to translate recommendations for diagnostic and therapeutic clinical care into clinical practice. Members of the AJRCCM editorial board will review these questions and assess the quality of the questions based on:
- Clarity,
- Educational content, and
- The quality of the evidence supporting the response to the question. Posttest questions will assess if practitioners have understood the most important recommendations available for the diagnosis and treatment of pulmonary diseases, critical illness, and sleep disorders and are able to implement them into clinical practice.
Article Authorship Disclosures (as submitted to the ATS prior to article publication date)
Antenor Rodrigues, P.T., Ph.D. (Unity Health Toronto, Toronto, Ontario, Canada) reported no relevant financial relationships.
Irene Telias, M.D. (Unity Health Toronto, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada; University Health Network and Sinai Health System, Toronto, Canada) reported a salary grant in the form of a postdoctoral fellowship from CIHR, consulting fees from MBMed, and teaching honoraria from Getinge and Medtronic.
L. Felipe Damiani, P.T., Ph.D. (Pontificia Universidad Católica de Chile, Santiago, Chile) reported grant FONDECYT 1220853 from ANID.
Laurent Brochard, M.D. (Unity Health Toronto, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada) reported grants or contracts directed to his institution from Medtronic, Draeger, and Air Liquide; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events directed to his institution from Fisher Paykel; patents planned, issued, or pending from General Electric; and receipt of equipment, materials, drugs, medical writing, gifts, or other services from Fisher Paykel and Sentec.
Disclosures of AJRCCM CME Planners
The current practice of the American Journal of Respiratory and Critical Care Medicine (AJRCCM) is to publish high quality, peer-reviewed and evidence-based original research, Concise Clinical Reviews, Guidelines and Consensus Statements. Articles published in AJRCCM include evidence-based summaries of optimal practice (Concise Clinical Reviews), evidence-based guidelines, workshop summaries and original contributions that will influence clinical practice. The publication of these articles by itself is only one piece of a multi-step process for the translation of evidence-based improvements in care to clinical practice. Articles selected for CME credit are designed to be the next step in the process of translating clinically relevant, evidence-based recommendations into clinical practice. This will be accomplished through a series of questions specifically designed by the author(s) to test that readers have the tools needed to translate recommendations for diagnostic and therapeutic clinical care into clinical practice. Members of the AJRCCM editorial board will review these questions and assess the quality of the questions based on (1) clarity, (2) educational content, and (3) the quality of the evidence supporting the response to the question. Posttest questions will assess if practitioners have understood the most important recommendations available for the diagnosis and treatment of pulmonary diseases, critical illness, and sleep disorders and are able to implement them into clinical practice.
Off-Label Usage Disclosure
None
AJRCCM CME Planners
Edward Schenck, M.D.
Associate Editor, AJRCCM
Dr. Schenck reported that he is a consultant for Axle Informatics
INSTRUCTIONS TO RECEIVE CREDIT
To receive credit for this journal article:
- Read the journal article. Keep track of how long it takes you to read it.
- Once you open the article, the Post-Test becomes available. After reading the article, answer the post-test questions. You must answer all questions correctly to earn credit. You may take the test as many times as you like.
- Once you pass the Post-Test, the Evaluation becomes available. Answer all the evaluation questions.
- Once you complete the evaluation, select the amount of credit to receive based on the time it took you to read the article.
- You can view, save and print your Certificate by pressing the Certificate button.
- To review the credits you've earned in this system and reprint certificates, go to the My Learning drop-down list. Then select Transcript.