Neuromuscular Blockade in Adult Respiratory Distress Syndrome.

Although current clinical practice guidelines have discordant conclusions, a judicious approach to using NMBA infusions may include reserving their use for patients with early severe ARDS who are already deeply sedated and for patients under light sedation who have significant ventilator dyssynchrony, despite attempts to adjust both ventilator settings and sedation requirements. Based on current evidence, the duration of NMBA use should be limited to 48 hours, whenever possible.

Inter-lung asymmetrical airway closure cause insufflation delay between lungs in acute hypoxemic respiratory failure.

BACKGROUND: Electrical Impedance Tomography (EIT) can quantify ventilation in the two lungs and be used to measure the airway opening pressure (AOP) of each lung. Asymmetrical AOPs can cause inter-lung insufflation delay. OBJECTIVES: To assess the relation between AOP asymmetry and inter-lung insufflation delay at different PEEP levels. METHODS: Patients with acute hypoxemic respiratory failure and airway closure were included. Low-flow pressure-volume curves and EIT signal were recorded during controlled ventilation and for some patients in pressure support ventilation. RESULTS: 23 patients were studied, 22 patients had ARDS, 9 patients had asymmetrical airway closure with an AOP of 10 [6-13] cmH20 in the sicker lung (AOPsicker) vs. 5 [3-9, ] cmH20 in the healthier lung. During a low flow inflation, the inter-lung inflation delay was 0 [0-112]ms vs. 1450 [375-2400]ms in patients without or with asymmetrical AOPs, p < 0.0001. This delay was correlated to the difference of AOP between the 2 lungs, Spearman R2 = 0.800, p < 0.0001. During tidal ventilation, median delay was 0 [0-62] ms vs. 150 [50-355] ms in patients without vs. with asymmetry, p = 0.019. Setting PEEP at the crossing point of a decremental EIT-based PEEP trial decreased the inter-lung insufflation delay. During pressure support insufflation delay could still be measured and was reduced by increasing PEEP from 5 to 10 cmH2O in patient with asymmetrical lung injury. CONCLUSION: In asymmetrical airway closure, titrating PEEP can minimize inter-lung insufflation delay and can be monitored by EIT. Reducing the delay and reducing ventilation asymmetry is also feasible during pressure support ventilation when low flow inflation curves cannot be performed.

Induction of subject-ventilator asynchrony by variation of respiratory parameters in a lung injury model in pigs.

BACKGROUND: Subject-ventilator asynchrony (SVA) was shown to be associated with negative clinical outcomes. To elucidate pathophysiology pathways and effects of SVA on lung tissue histology a reproducible animal model of artificially induced asynchrony was developed and evaluated. METHODS: Alterations in ventilator parameters were used to induce the three main types of asynchrony: ineffective efforts (IE), auto-triggering (AT), and double-triggering (DT). Airway flow and pressure, as well as oesophageal pressure waveforms, were recorded, asynchrony cycles were manually classified and the asynchrony index (AIX) was calculated. Bench tests were conducted on an active lung simulator with ventilator settings altered cycle by cycle. The developed algorithm was evaluated in three pilot experiments and a study in pigs ventilated for twelve hours with AIX = 25%. RESULTS: IE and AT were induced reliably and fail-safe by end-expiratory hold and adjustment of respiratory rate, respectively. DT was provoked using airway pressure ramp prolongation, however not controlled specifically in the pilots. In the subsequent study, an AIX = 28.8% [24.0%-34.4%] was induced and maintained over twelve hours. CONCLUSIONS: The method allows to reproducibly induce and maintain three clinically relevant types of SVA observed in ventilated patients and may thus serve as a useful tool for future investigations on cellular and inflammatory effects of asynchrony.

Appearance-Related Victimization and Pubertal Asynchrony: Identifying Sex-Specific Vulnerabilities.

Pubertal development is associated with many psychosocial and interpersonal changes, including a dramatic rise in appearance-related victimization. Yet, it is unclear what aspects of pubertal development provoke victimization along with which, and when, youth are at heightened risk. The present study seeks to address this gap by examining the effect of pubertal asynchrony (i.e., temporal variation in an individual's pubertal milestones) on appearance-related victimization and by determining whether associations between asynchrony and victimization differ by sex and pubertal status. In follow-up analyses, associations between pubertal asynchrony and different typologies of victimization were also assessed. Participants included 373 youth (Mage = 13.51 [1.62]; 40% girls, 60% boys; 61% White) drawn from an online sample. The results showed that more pubertal asynchrony was associated with more appearance-related victimization, especially for girls, but associations did not differ across pubertal status. Latent profile analyses of appearance-related victimization further suggested that asynchronous youth were more likely to be in profiles characterized by high appearance-related victimization as well as those characterized by high height-based victimization (boys only). The findings suggest that pubertal asynchrony contributes to appearance-related victimization in adolescence and highlights the need for targeted intervention efforts related to pubertal development and specific typologies of victimization.

Post-insufflation diaphragm contractions in patients receiving various modes of mechanical ventilation.

BACKGROUND: During mechanical ventilation, post-insufflation diaphragm contractions (PIDCs) are non-physiologic and could be injurious. PIDCs could be frequent during reverse-triggering, where diaphragm contractions follow the ventilator rhythm. Whether PIDCs happens with different modes of assisted ventilation is unknown. In mechanically ventilated patients with hypoxemic respiratory failure, we aimed to examine whether PIDCs are associated with ventilator settings, patients' characteristics or both. METHODS: One-hour recordings of diaphragm electromyography (EAdi), airway pressure and flow were collected once per day for up to five days from intubation until full recovery of diaphragm activity or death. Each breath was classified as mandatory (without-reverse-triggering), reverse-triggering, or patient triggered. Reverse triggering was further subclassified according to EAdi timing relative to ventilator cycle or reverse triggering leading to breath-stacking. EAdi timing (onset, offset), peak and neural inspiratory time (Tineuro) were measured breath-by-breath and compared to the ventilator expiratory time. A multivariable logistic regression model was used to investigate factors independently associated with PIDCs, including EAdi timing, amplitude, Tineuro, ventilator settings and APACHE II. RESULTS: Forty-seven patients (median[25%-75%IQR] age: 63[52-77] years, BMI: 24.9[22.9-33.7] kg/m2, 49% male, APACHE II: 21[19-28]) contributed 2 ± 1 recordings each, totaling 183,962 breaths. PIDCs occurred in 74% of reverse-triggering, 27% of pressure support breaths, 21% of assist-control breaths, 5% of Neurally Adjusted Ventilatory Assist (NAVA) breaths. PIDCs were associated with higher EAdi peak (odds ratio [OR][95%CI] 1.01[1.01;1.01], longer Tineuro (OR 37.59[34.50;40.98]), shorter ventilator inspiratory time (OR 0.27[0.24;0.30]), high peak inspiratory flow (OR 0.22[0.20;0.26]), and small tidal volumes (OR 0.31[0.25;0.37]) (all P ≤ 0.008). NAVA was associated with absence of PIDCs (OR 0.03[0.02;0.03]; P < 0.001). Reverse triggering was characterized by lower EAdi peak than breaths triggered under pressure support and associated with small tidal volume and shorter set inspiratory time than breaths triggered under assist-control (all P < 0.05). Reverse triggering leading to breath stacking was characterized by higher peak EAdi and longer Tineuro and associated with small tidal volumes compared to all other reverse-triggering phenotypes (all P < 0.05). CONCLUSIONS: In critically ill mechanically ventilated patients, PIDCs and reverse triggering phenotypes were associated with potentially modifiable factors, including ventilator settings. Proportional modes like NAVA represent a solution abolishing PIDCs.

Population asynchrony within and between trophic levels have contrasting effects on consumer community stability in a subtropical lake.

Clarifying the effects of biodiversity on ecosystem stability in the context of global environmental change is crucial for maintaining ecosystem functions and services. Asynchronous changes between trophic levels over time (i.e. trophic community asynchrony) are expected to increase trophic mismatch and alter trophic interactions, which may consequently alter ecosystem stability. However, previous studies have often highlighted the stabilising mechanism of population asynchrony within a single trophic level, while rarely examining the mechanism of trophic community asynchrony between consumers and their food resources. In this study, we analysed the effects of population asynchrony within and between trophic levels on community stability under the disturbances of climate warming, fishery decline and de-eutrophication, based on an 18-year monthly monitoring dataset of 137 phytoplankton and 91 zooplankton in a subtropical lake. Our results showed that species diversity promoted community stability mainly by increasing population asynchrony both for phytoplankton and zooplankton. Trophic community asynchrony had a significant negative effect on zooplankton community stability rather than that of phytoplankton, which supports the match-mismatch hypothesis that trophic mismatch has negative effects on consumers. Furthermore, the results of the structural equation models showed that warming and top-down effects may simultaneously alter community stability through population dynamics processes within and between trophic levels, whereas nutrients act on community stability mainly through the processes within trophic levels. Moreover, we found that rising water temperature decreased trophic community asynchrony, which may challenge the prevailing idea that climate warming increases the trophic mismatch between primary producers and consumers. Overall, our study provides the first evidence that population and trophic community asynchrony have contrasting effects on consumer community stability, which offers a valuable insight for addressing global environmental change.

Arrival-breeding interval is flexible in a songbird and is not constrained by migration carry-over effects.

As spring phenology advances with climate change, so too must the timing of life cycle events. Breeding at the right time is critical in many species as it maximizes fitness. For long-distance migratory birds, flexibility in the duration of the arrival-breeding interval (pre-breeding period) may allow populations to adjust their timing of breeding. However, whether first egg-lay dates are flexible to local environmental conditions after arrival, and if they are constrained by the time needed to replenish energy lost during migration, remains unclear. We investigated the regional flexibility of the arrival-breeding interval in an avian migrant, the purple martin, Progne subis, across their breeding range. We evaluated whether the duration of the arrival-breeding interval was flexible to temperature and precipitation at breeding sites, and if timing was limited by migration rate and stopover duration. We also tested if longer interval durations were associated with higher fledging success. To address our hypotheses, we used a combination of migration tracking, weather and breeding data collected from four regions across eastern North America (26.1° N to 52.4° N latitude). We found the arrival-breeding interval to be shortest in the north and longest in the south. Across all regions, warmer temperatures encountered at breeding grounds were associated with shorter intervals, and faster migration rates led to longer intervals. The length of the interval was not influenced by precipitation or stopover duration. Finally, longer intervals were not associated with higher fledge success. Currently, the longer arrival-breeding intervals in this study system, on average 28.3 days, may provide both early and late-arriving birds with ample time for recovery so birds can lay eggs according to temperature. Any negative effects of faster migration may have been buffered by longer arrival-breeding intervals, as interval length did not determine fledge success. With ongoing climate change, further research is needed to examine if arrival-breeding intervals become constrained by migration timing, which may limit opportunities for migrants to match the timing of breeding with key resources.

Phase-dependent grassland temporal stability is mediated by species and functional group asynchrony: A long-term mowing experiment.

The temporal stability of grasslands plays a key role in the stable provisioning of multiple ecosystem goods and services for humankind. Despite recent progress, our knowledge on how long-term mowing influences ecosystem stability remains unclear. Using a dataset from an 18-year-long mowing experiment with different treatment intensities (no-mowing, mowing once per year, and mowing twice per year) in grasslands of Inner Mongolia, China, we aimed to determine whether and how long-term mowing influenced grassland temporal stability in a temperate steppe. We found mowing decreased ecosystem stability in the early and intermediate periods (1-12 years of treatment), but increased stability in the later period (13-18 years of treatment), indicating responses of ecosystem stability to long-term mowing were phase dependent. Bivariate correlation and structural equation modeling analyses revealed that the degree of asynchrony both at the species and functional group levels, as well as dominant species stability, played key roles in stabilizing the whole community. In addition, portfolio effects rather than diversity made significant contributions to ecosystem stability. Our results suggest the phase-dependent temporal stability of grassland under long-term mowing is mainly mediated by species and functional group asynchrony. This finding provides a new insight for understanding how dryland grassland responds to long-term anthropogenic perturbations.

Critical care nurses' knowledge and attitudes towards using ventilator waveform monitoring to detect patient-ventilator asynchrony: A cross-sectional online survey.

BACKGROUND: Patient-ventilator asynchrony (PVA) is a condition that commonly affects patients who are mechanically ventilated. PVA happens when the patient's own breathing effort and the ventilator preset settings are out of sync. Ventilator waveform monitoring is viewed as a difficult undertaking, even for experienced practitioners, despite being a non-invasive and reliable tool for diagnosing PVA. AIM: To assess the knowledge levels and attitudes of critical care nurses (CCNs) regarding the use of ventilator waveform monitoring to detect PVA. STUDY DESIGN: A cross-sectional online survey was conducted in three intensive care units (ICUs) in Alexandria, Egypt. The questionnaire consisted of four parts to evaluate CCNs' level of knowledge and attitude regarding ventilator waveform monitoring and assess their ability to detect PVA. RESULTS: Of the 137 CCNs approached, 101 CCNs completed the survey, resulting in a 73.7% response rate. Most nurses (88.1%) demonstrated poor knowledge levels and negative attitudes (93.1%) towards using waveform monitoring to detect PVA. A significant relationship was found between nurses' knowledge of ventilator waveform monitoring and their participation in previous training programmes on mechanical ventilation (MV; p = .031). Additionally, nurses' attitudes towards ventilator waveform monitoring were significantly associated with their level of education (p = .002) and attendance in previous courses on waveform analysis (p = .020). CONCLUSIONS: A majority of CCNs have poor knowledge and negative attitudes regarding ventilator waveform monitoring. Previous training in MV and attendance courses on ventilator waveform analysis showed a significant correlation between nurses' level of knowledge and attitudes regarding ventilator waveform monitoring. RELEVANCE TO CLINICAL PRACTICE: Assessment of CCNs' knowledge and attitudes regarding ventilator waveform monitoring for detecting patient-ventilator asynchrony (PVA) informs the development of future educational programmes, ultimately aiding in the delivery of prompt and high-quality care.

Temporal asynchrony of plant and soil biota determines ecosystem multifunctional stability.

The role of plant biodiversity in stabilizing ecosystem multifunctionality has been extensively studied; however, the impact of soil biota biodiversity on ecosystem multifunctional stability, particularly under multiple environmental changes, remains unexplored. By conducting an experiment with environmental changes (adding water and nitrogen to a long-term grazing experiment) and an experiment without environmental changes (an undisturbed site) in semi-arid grasslands, our research revealed that environmental changes-induced changes in temporal stability of both above- and belowground multifunctionality were mainly impacted by plant and soil biota asynchrony, rather than by species diversity. Furthermore, changes in temporal stability of above- and belowground multifunctionality, under both experiments with and without environmental changes, were mainly associated with plant and soil biota asynchrony, respectively, suggesting that the temporal asynchrony of plant and soil biota has independent and non-substitutable effects on multifunctional stability. Our findings emphasize the importance of considering both above- and belowground biodiversity or functions when evaluating the stabilizing effects of biodiversity on ecosystem functions.

Bilateral Endogenous Bacterial Endophthalmitis with Asynchrony for 14 Months due to Klebsiella pneumoniae: A Case Report.

Introduction: The aim of this study was to describe a very rare case of endogenous bacterial endophthalmitis caused by Klebsiella pneumoniae in both eyes with a difference in the onset of symptoms of 14 months in an immunocompetent patient. Case Presentation: A 66-year-old immunocompetent man presented with asynchronous bilateral endogenous endophthalmitis produced by the K. pneumoniae bacterium at the starting point of a liver abscess after cholecystectomy surgery, causing endophthalmitis 1 year and 2 months apart between an eye and another. The first was diffuse anteroposterior endophthalmitis in the left eye that ended in visual loss and phthisis bulbi due to delayed initial diagnosis and established treatment, and the second was focal endophthalmitis in the right eye that preserved the organ and resulted in a vision of 20/20 due to early suspected diagnosis and rapid instituted treatment. Conclusion: To our knowledge, this is the first published case of a long asynchronous bilateral endogenous bacterial endophthalmitis caused by K. pneumoniae with a prolonged difference of 14 months in the onset of symptoms between one eye and another. This case is a vision-threatening ophthalmologic emergency that can be associated with life-threatening systemic morbidities. The early diagnosis of infection represents a challenge for clinicians, ophthalmologists, and microbiologists.

Clinical evidence and technical aspects of innovative technology and monitoring of chronic NIV in COPD: a narrative review.

INTRODUCTION: Chronic nocturnal noninvasive ventilation (NIV) improves outcomes in COPD patients with chronic hypercapnic respiratory failure. The aim of chronic NIV in COPD is to control chronic hypercapnic respiratory insufficiency and reduce symptoms of nocturnal hypoventilation, thereby improving quality of life. Chronic NIV care is more and more offered exclusively at home, enabling promising outcomes in terms of patient and caregiver satisfaction, hospital care consumption and cost reduction. Yet, to achieve and maintain optimal ventilation, during adaptation and follow-up, effective feasible (home) monitoring poses a significant challenge. AREAS COVERED: Comprehensive monitoring of COPD patients receiving chronic NIV requires integrating data from ventilators and assessment of the patient's status including gas exchange, sleep quality, and patient-reported outcomes. The present article describes the physiological background of monitoring during NIV and aims to provide an overview of existing methods for monitoring, assessing their reliability and clinical relevance. EXPERT OPINION: Patients on chronic NIV are 'ideal' candidates for home monitoring; the advantages of transforming hospital to home care are huge for patients and caregivers and for healthcare systems facing increasing patient numbers. Despite the multitude of available monitoring methods, identifying and characterizing the most relevant parameters associated with optimal patient well-being remains unclear.

Application of a cloud platform that identifies patient-ventilator asynchrony and enables continuous monitoring of mechanical ventilation in intensive care unit.

Background: Patient-ventilator asynchrony (PVA) frequently occurs in mechanically ventilated patients within the ICU and has the potential for harm. Depending solely on the health care team cannot accurately and promptly identify PVA. To address this issue, our team has developed a cloud-based platform for monitoring mechanical ventilation (MV), comprising the PVA-RemoteMonitor system and the 24-h MV analysis report. We conducted a survey to evaluate physicians' satisfaction and acceptance of the platform in 14 ICUs. Methods: Data from medical records, clinical information systems, and ventilators were uploaded to the cloud platform and underwent data processing. The data were analyzed to monitor PVA and displayed in the front-end. The 24-h analysis report for MV was generated for clinical reference. Critical care physicians in 14 hospitals' ICUs that involved in the platform participated in a questionnaire survey, among whom 10 physicians were interviewed to investigate physicians' acceptance and opinions of this system. Results: The PVA-RemoteMonitor system exhibited a high level of specificity in detecting flow insufficiency, premature cycle, delayed cycle, reverse trigger, auto trigger, and overshoot, with sensitivities of 90.31 %, 98.76 %, 99.75 %, 99.97 %, 100 %, and 99.69 %, respectively. The 24-h analysis report supplied essential data about PVA and respiratory mechanics. 86.2 % (75/87) of physicians supported the application of this platform. Conclusions: The PVA-RemoteMonitor system accurately identified PVA, and the MV analysis report provided guidance in controlling PVA. Our platform can effectively assist ICU physicians in the management of ventilated patients.

Patient-ventilator asynchrony classification in mechanically ventilated patients: Model-based or machine learning method?

BACKGROUND AND OBJECTIVE: Patient-ventilator asynchrony (PVA) is associated with poor clinical outcomes and remains under-monitored. Automated PVA detection would enable complete monitoring standard observational methods do not allow. While model-based and machine learning PVA approaches exist, they have variable performance and can miss specific PVA events. This study compares a model and rule-based algorithm with a machine learning PVA method by retrospectively validating both methods using an independent patient cohort. METHODS: Hysteresis loop analysis (HLA) which is a rule-based method (RBM) and a tri-input convolutional neural network (TCNN) machine learning model are used to classify 7 different types of PVA, including: 1) flow asynchrony; 2) reverse triggering; 3) premature cycling; 4) double triggering; 5) delayed cycling; 6) ineffective efforts; and 7) auto triggering. Class activation mapping (CAM) heatmaps visualise sections of respiratory waveforms the TCNN model uses for decision making, improving result interpretability. Both PVA classification methods were used to classify incidence in an independent retrospective clinical cohort of 11 mechanically ventilated patients for validation and performance comparison. RESULTS: Self-validation with the training dataset shows overall better HLA performance (accuracy, sensitivity, specificity: 97.5 %, 96.6 %, 98.1 %) compared to the TCNN model (accuracy, sensitivity, specificity: 89.5 %, 98.3 %, 83.9 %). In this study, the TCNN model demonstrates higher sensitivity in detecting PVA, but HLA was better at identifying non-PVA breathing cycles due to its rule-based nature. While the overall AI identified by both classification methods are very similar, the intra-patient distribution of each PVA type varies between HLA and TCNN. CONCLUSION: The collective findings underscore the efficacy of both HLA and TCNN in PVA detection, indicating the potential for real-time continuous monitoring of PVA. While ML methods such as TCNN demonstrate good PVA identification performance, it is essential to ensure optimal model architecture and diversity in training data before widespread uptake as standard care. Moving forward, further validation and adoption of RBM methods, such as HLA, offers an effective approach to PVA detection while providing clear distinction into the underlying patterns of PVA, better aligning with clinical needs for transparency, explicability, adaptability and reliability of these emerging tools for clinical care.

Combined effects of heat waves and pesticide pollution on zooplankton communities: Does the timing of stressor matter?

Most studies assessing the combined effects of chemical and non-chemical stressors on aquatic ecosystems have been based on synchronous stressor applications. However, asynchronous exposure scenarios may be more common in nature, particularly for pulsed stressors such as heatwaves and pesticide concentration peaks. In this study, we investigated the single and combined effects of the insecticide chlorpyrifos (CPF) and a heatwave (HW) on a zooplankton community representative of a Mediterranean coastal wetland using synchronous (CPF+HW) and asynchronous (HW→CPF and CPF→HW) exposure scenarios. CPF was applied at a concentration of 0.8 µg/L (single pulse), and the HW was simulated by a temperature increase of 8°C above the control temperature (20°C) for 7 days in freshwater microcosms. The interaction between stressors in synchrony resulted in synergistic effects at the population level (Daphnia magna) and additive at the community level. The partial reduction of sensitive species resulted in an abundance increase of competing species that were more tolerant to the evaluated stressors (e.g. Moina sp.). The asynchronous exposure scenarios resulted in a similar abundance decline of sensitive populations as compared to the synchronous one; however, the timing of stressor resulted in different responses in the long term. In the HW→CPF treatment, the D. magna population recovered at least one month faster than in the CPF+HW treatment, probably due to survival selection and cross-tolerance mechanisms. In the CPF→HW treatment, the effects lasted longer than in the CPF+HW, and the population did not recover within the experimental period, most likely due to the energetic costs of detoxification and effects on internal damage recovery. The different timing and magnitude of indirect effects among the tested asynchronous scenarios resulted in more severe effects on the structure of the zooplankton community in the CPF→HW treatment. Our study highlights the relevance of considering the order of stressors to predict the long-term effects of chemicals and heatwaves both at the population and community levels.

Knowledge and associated factors of healthcare professionals in detecting patient-ventilator asynchrony using waveform analysis at intensive care units of the federal public hospitals in Addis Ababa, Ethiopia, 2023.

BACKGROUND: The interaction between the patient and the ventilator is often disturbed, resulting in patient-ventilator asynchrony (PVA). Asynchrony can lead to respiratory failure, increased artificial ventilation time, prolonged hospitalization, and escalated healthcare costs. Professionals' knowledge regarding waveform analysis has significant implications for improving patient outcomes and minimizing ventilation-related adverse events. Studies investigating the knowledge of healthcare professionals on patient-ventilator asynchrony and its associated factors in the Ethiopian context are limited. Therefore, this study aimed to assess the knowledge of healthcare professionals about using waveform analysis to detect asynchrony. METHODS: A multicenter cross-sectional study was conducted on 237 healthcare professionals (HCPs) working in the intensive care units (ICUs) of federal public hospitals in Addis Ababa, Ethiopia, from December 2022 to May 2023. The data were collected using a structured and pretested interviewer-administered questionnaire. Then, the collected data were cleaned, coded, and entered into Epi data V-4.2.2 and exported to SPSS V-27 for analysis. After description, associations were analyzed using binary logistic regression. Variables with a P-value of < 0.25 in the bivariable analysis were transferred to the multivariable analysis. Statistical significance was declared using 95% confidence intervals, and the strengths of associations were reported using adjusted odds ratios (AORs). RESULTS: A total of 237 HCPs participated in the study with a response rate of 100%. Half (49.8%) of the participants were females. The mean age of the participants was 29 years (SD = 3.57). Overall, 10.5% (95% CI: 6.9-15.2) of the participants had good knowledge of detecting PVA using waveform analysis. In the logistic regression, the number of MV-specific trainings and the training site had a statistically significant association with knowledge of HCPs. HCPs who attended more frequent MV training were more likely to have good knowledge than their counterparts [AOR = 6.88 (95% CI: 2.61-15.45)]. Additionally, the odds of good knowledge among professionals who attended offsite training were 2.6 times higher than those among professionals trained onsite [AOR = 2.63 (95% CI: 1.36-7.98)]. CONCLUSION: The knowledge of ICU healthcare professionals about the identification of PVA using waveform analysis is low. In addition, the study also showed that attending offsite MV training and repeated MV training sessions were independently associated with good knowledge. Consequently, the study findings magnify the relevance of providing frequent and specific training sessions focused on waveform analysis to boost the knowledge of HCPs.

Reverse triggering ? a novel or previously missed phenomenon?

BACKGROUND: Reverse triggering (RT) was described in 2013 as a form of patient-ventilator asynchrony, where patient's respiratory effort follows mechanical insufflation. Diagnosis requires esophageal pressure (Pes) or diaphragmatic electrical activity (EAdi), but RT can also be diagnosed using standard ventilator waveforms. HYPOTHESIS: We wondered (1) how frequently RT would be present but undetected in the figures from literature, especially before 2013; (2) whether it would be more prevalent in the era of small tidal volumes after 2000. METHODS: We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials, from 1950 to 2017, with key words related to asynchrony to identify papers with figures including ventilator waveforms expected to display RT if present. Experts labelled waveforms. 'Definite' RT was identified when Pes or EAdi were in the tracing, and 'possible' RT when only flow and pressure waveforms were present. Expert assessment was compared to the author's descriptions of waveforms. RESULTS: We found 65 appropriate papers published from 1977 to now, containing 181 ventilator waveforms. 21 cases of 'possible' RT and 25 cases of 'definite' RT were identified by the experts. 18.8% of waveforms prior to 2013 had evidence of RT. Most cases were published after 2000 (1 before vs. 45 after, p = 0.03). 54% of RT cases were attributed to different phenomena. A few cases of identified RT were already described prior to 2013 using different terminology (earliest in 1997). While RT cases attributed to different phenomena decreased after 2013, 60% of 'possible' RT remained missed. CONCLUSION: RT has been present in the literature as early as 1997, but most cases were found after the introduction of low tidal volume ventilation in 2000. Following 2013, the number of undetected cases decreased, but RT are still commonly missed. Reverse Triggering, A Missed Phenomenon in the Literature. Critical Care Canada Forum 2019 Abstracts. Can J Anesth/J Can Anesth 67 (Suppl 1), 1-162 (2020). https://doi-org.myaccess.library.utoronto.ca/ https://doi.org/10.1007/s12630-019-01552-z .

Buffering and phenological mismatch: A change of perspective.

The potential for climate change to disrupt phenology-mediated interactions in interaction networks has attracted considerable attention in recent decades. Frequently, studies emphasize the fragility of ephemeral seasonal interactions, and the risks posed by phenological asynchrony. Here, we argue that the fitness consequences of asynchrony in phenological interactions may often be more buffered than is typically acknowledged. We identify three main forms that buffering may take: (i) mechanisms that reduce asynchrony between consumer and resource; (ii) mechanisms that reduce the costs of being asynchronous; and (iii) mechanisms that dampen interannual variance in performance across higher organizational units. Using synchrony between the hatching of winter moth caterpillars and the leafing of their host-plants as a case study, we identify a wide variety of buffers that reduce the detrimental consequences of phenological asynchrony on caterpillar individuals, populations, and meta-populations. We follow this by drawing on examples across a breadth of taxa, and demonstrate that these buffering mechanisms may be quite general. We conclude by identifying key gaps in our knowledge of the fitness and demographic consequences of buffering, in the context of phenological mismatch. Buffering has the potential to substantially alter our understanding of the biotic impacts of future climate change-a greater recognition of the contribution of these mechanisms may reveal that many trophic interactions are surprisingly resilient, and also serve to shift research emphasis to those systems with fewer buffers and towards identifying the limits of those buffers.

The effects of real-time waveform analysis software on patient ventilator synchronization during pressure support ventilation: a randomized crossover physiological study.

BACKGROUND: Patient-ventilator asynchrony commonly occurs during pressure support ventilation (PSV). IntelliSync + software (Hamilton Medical AG, Bonaduz, Switzerland) is a new ventilation technology that continuously analyzes ventilator waveforms to detect the beginning and end of patient inspiration in real time. This study aimed to evaluate the physiological effect of IntelliSync + software on inspiratory trigger delay time, delta airway (Paw) and esophageal (Pes) pressure drop during the trigger phase, airway occlusion pressure at 0.1 s (P0.1), and hemodynamic variables. METHODS: A randomized crossover physiologic study was conducted in 14 mechanically ventilated patients under PSV. Patients were randomly assigned to receive conventional flow trigger and cycling, inspiratory trigger synchronization (I-sync), cycle synchronization (C-sync), and inspiratory trigger and cycle synchronization (I/C-sync) for 15 min at each step. Other ventilator settings were kept constant. Paw, Pes, airflow, P0.1, respiratory rate, SpO2, and hemodynamic variables were recorded. The primary outcome was inspiratory trigger and cycle delay time between each intervention. Secondary outcomes were delta Paw and Pes drop during the trigger phase, P0.1, SpO2, and hemodynamic variables. RESULTS: The time to initiate the trigger was significantly shorter with I-sync compared to baseline (208.9±91.7 vs. 301.4±131.7 msec; P = 0.002) and I/C-sync compared to baseline (222.8±94.0 vs. 301.4±131.7 msec; P = 0.005). The I/C-sync group had significantly lower delta Paw and Pes drop during the trigger phase compared to C-sync group (-0.7±0.4 vs. -1.2±0.8 cmH2O; P = 0.028 and - 1.8±2.2 vs. -2.8±3.2 cmH2O; P = 0.011, respectively). No statistically significant differences were found in cycle delay time, P0.1 and other physiological variables between the groups. CONCLUSIONS: IntelliSync + software reduced inspiratory trigger delay time compared to the conventional flow trigger system during PSV mode. However, no significant improvements in cycle delay time and other physiological variables were observed with IntelliSync + software. TRIAL REGISTRATION: This study was registered in the Thai Clinical Trial Registry (TCTR20200528003; date of registration 28/05/2020).