Effect of Reverse Triggering With Breath Stacking and Related Risk Factors in ICU Patients

Introduction: Reverse triggering (RT) is a complex form of asynchrony with different phenotypes and their clinical implications are underexplored in patients with pressure-controlled ventilation (PCV). This study aimed at determining the incidence of RT using a long-term monitoring platform, characterizing the breath stacking’s effects and identifying risk factors associated with poor outcome.


Methods: Patients with PCV between January 2023 and June 2024 under the Remote-VentilateView system for at least 24 hours and RT frequency ≥2% were included. We investigated two phenotypes of RT (with and without breath stacking) and monitored their effects on ventilator-induced lung injury (VILI). We also calculated additional stacking volume and screened out the risk factors associated with prolonged mechanical ventilation and higher additional stacking volume in RT with breath stacking.


Results: Among 870 patients with mechanical ventilation under the platform, 174 patients (20.0%) occurred RT and 80 patients of those had breath stacking. RT breath stacking was associated with higher plateau pressure [15.4 (14.3, 17.0) cmHâ‚‚O vs. 13.7 (11.4, 15.0) cmHâ‚‚O], driving pressure (DP) [8.5 (7.5, 10.0) cmHâ‚‚O vs. 7.0 (5.8, 9.0) cmHâ‚‚O] and longer duration of mechanical ventilation [7 (3, 15) days vs. 4 (2, 7) days]. ROC analysis has provided an additional stacking volume threshold of 141 ml that associated with prolonged mechanical ventilation. Higher APACHE II score (OR, 1.215; 95% CI, 1.047-1.409), lower oxygenation index (OR, 0.993; 95% CI, 0.989-0.997), lower value of Cdyn (OR, 0.956; 95% CI, 0.905-0.998), more fentanyl infusion (OR, 1.082; 95% CI, 1.006-1.162) and lower dexmedetomidine usage (OR, 0.046; 95% CI, 0.004-0.491) were associated with prolonged mechanical ventilation. Higher level of DP (OR, 1.572; 95% CI, 1.048-2.347) and PaCO2 (OR, 1.186; 95% CI, 1.056-1.334), more fentanyl infusion (OR, 1.031; 95% CI, 1.002-1.062), lower usage of dexmedetomidine (OR, 0.301; 95% CI, 0.108-0.837) were risk factors for greater stacking volume.


Conclusions: RT with breath stacking under PCV was characterized by higher plateau pressure and DP. PaCO2 and fentanyl are risk factors associated with higher additional stacking volume. Dexmedetomidine may have beneficial effects on duration of mechanical ventilation and stacking volume.