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Abstract
Discussion Forum (0)
ePoster
Topic: Safe Ventilation and Oxygenation

Grassi, Alice1; Bianchi, Isabella2; Jonkman, Annemjin3,4; Telias, Irene3; Vieira, Fernando3; Teggia Droghi, Maddalena5; Pham, Tai3; Bellani, Giacomo5; Brochard, Laurent3
1 Department of anesthesiology and pain medicine, University of Toronto, Toronto, Canada
2 Department of critical care and anesthesia, ASST Papa Giovanni XXIII, Bergamo, Italy
3 Interdepartmental division of critical care medicine, University of Toronto, Toronto, Canada
4 Department of Intensive Care Medicine, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
5 School of medicine and surgery, University of Milan-Bicocca, Monza, Italy
Department of Anesthesiology and Pain Medicine, University of Toronto

INTRODUCTION:
Evidence has emerged that driving pressure during pressure support ventilation (PSV) is associated with outcome, as in controlled mechanical ventilation[1]. This measurement, however, is not routinely performed, as it requires a reliable assessment of Plateau Pressure (Pplat) during an inspiratory hold. In fact, not all ventilators allow to perform an inspiratory hold during assisted ventilation modes and the interpretation of the result might not be straightforward because of ongoing patient's muscular activity. Nevertheless, the Pplat value can be of invaluable help in clinical practice, both to compute driving pressure under PSV[1] and to monitor patient's inspiratory effort[2].
OBJECTIVES
To evaluate the reliability in assessing inspiratory holds performed during PSV as general 'readability' (determining if the hold reveals a stable airway Pplat) and as the value and duration of the plateau.
METHODS
This is an ancillary analysis of pressure and flow curves obtained during a multicenter observational study aimed to describe the incidence of patient-ventilator asynchronies in ARDS patients (BEARDS, NCT03447288). Tracings were evaluated by six independent raters, experienced with ventilator waveforms assessment. We selected tracings with an inspiratory hold and a reliable Pes tracing acquired simultaneously. The raters evaluated the same tracing twice, with and without a Pes tracing available, and in random order (Fig1-2). For each tracing, raters were asked to determine the readability of the plateau (readable yes/no) based on the following criteria: 1) flat plateau 2) zero flow 3) in presence of inspiratory efforts, flat plateau before and after the efforts. For the holds considered readable, the value of the plateau and its duration were measured.
Krippendorf's alpha (α) test was used to estimate the interobserver agreement on the general readability of the hold. Intraclass correlation coefficient (ICC) was used to estimate the agreement on continuous variables. α and ICC values >0.75 were considered as good agreement. 
RESULTS
91 tracings (35patients from 11centers) were selected for analysis. The interobserver agreement on the general readability of the hold when evaluating ventilator tracings without Pes available was relatively low (α=0.466 [0.418-0.513]) and increased slightly when Pes tracing was added (α=0.502 [0.458-0.555]). Considering the tracings without Pes, the raters reached an 100% agreement on 37 plateaus (15 of which were considered non readable and 22 readable). When the Pes tracing was added, 100% agreement was reached in 43 out of 91 holds, 13 considered not readable and 30 readable. There was perfect agreement on the Pplat value for the 30 holds which reached universal agreement on readability (0.999 [0.998-1.000] for the tracings with Pes). On average, intra-rater agreement for the 22 Pplat values as scored with and without Pes tracings visible was 0.919. In regards of the duration of the Pplat, the ICC was 0.770 [0.571-0.898] for the tracings without Pes and 0.810 [0.661-0.905] for the tracings with Pes.
CONCLUSION
The interobserver agreement in evaluating inspiratory holds during PSV was relatively low, but when an agreement was reached the interpretation of the value and duration of the plateau were very consistent among raters, as well as the intra-rater agreement in evaluating the same hold with and without Pes. Further analyses are ongoing to evaluate 1)the main reasons for which holds were not uniformly interpreted 2)the features of readable holds.

Image 1
Image 2

1. Driving Pressure Is Associated with Outcome during Assisted Ventilation in Acute Respiratory Distress Syndrome. G. Bellani, A. Grassi, S. Sosio, S. Gatti, B. P. Kavanagh, A. Pesenti, G. Foti. 2019, Anesthesiology, Vol. 131, pp. 594–604.
2. End-Inspiratory Airway Occlusion. A Method To Assess the Pressure Developed by Inspiratory Muscles in Patients with Acute Lung Injury Undergoing Pressure Support. G. Foti, M. Cereda, G. Banfi, P. Pelosi, R. Fumagalli, A. Pesenti. 1997, Am J Respir Crit Care Med, Vol. 156, pp. 1210–1216.
 
ePoster
Topic: Safe Ventilation and Oxygenation

Grassi, Alice1; Bianchi, Isabella2; Jonkman, Annemjin3,4; Telias, Irene3; Vieira, Fernando3; Teggia Droghi, Maddalena5; Pham, Tai3; Bellani, Giacomo5; Brochard, Laurent3
1 Department of anesthesiology and pain medicine, University of Toronto, Toronto, Canada
2 Department of critical care and anesthesia, ASST Papa Giovanni XXIII, Bergamo, Italy
3 Interdepartmental division of critical care medicine, University of Toronto, Toronto, Canada
4 Department of Intensive Care Medicine, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
5 School of medicine and surgery, University of Milan-Bicocca, Monza, Italy
Department of Anesthesiology and Pain Medicine, University of Toronto

INTRODUCTION:
Evidence has emerged that driving pressure during pressure support ventilation (PSV) is associated with outcome, as in controlled mechanical ventilation[1]. This measurement, however, is not routinely performed, as it requires a reliable assessment of Plateau Pressure (Pplat) during an inspiratory hold. In fact, not all ventilators allow to perform an inspiratory hold during assisted ventilation modes and the interpretation of the result might not be straightforward because of ongoing patient's muscular activity. Nevertheless, the Pplat value can be of invaluable help in clinical practice, both to compute driving pressure under PSV[1] and to monitor patient's inspiratory effort[2].
OBJECTIVES
To evaluate the reliability in assessing inspiratory holds performed during PSV as general 'readability' (determining if the hold reveals a stable airway Pplat) and as the value and duration of the plateau.
METHODS
This is an ancillary analysis of pressure and flow curves obtained during a multicenter observational study aimed to describe the incidence of patient-ventilator asynchronies in ARDS patients (BEARDS, NCT03447288). Tracings were evaluated by six independent raters, experienced with ventilator waveforms assessment. We selected tracings with an inspiratory hold and a reliable Pes tracing acquired simultaneously. The raters evaluated the same tracing twice, with and without a Pes tracing available, and in random order (Fig1-2). For each tracing, raters were asked to determine the readability of the plateau (readable yes/no) based on the following criteria: 1) flat plateau 2) zero flow 3) in presence of inspiratory efforts, flat plateau before and after the efforts. For the holds considered readable, the value of the plateau and its duration were measured.
Krippendorf's alpha (α) test was used to estimate the interobserver agreement on the general readability of the hold. Intraclass correlation coefficient (ICC) was used to estimate the agreement on continuous variables. α and ICC values >0.75 were considered as good agreement. 
RESULTS
91 tracings (35patients from 11centers) were selected for analysis. The interobserver agreement on the general readability of the hold when evaluating ventilator tracings without Pes available was relatively low (α=0.466 [0.418-0.513]) and increased slightly when Pes tracing was added (α=0.502 [0.458-0.555]). Considering the tracings without Pes, the raters reached an 100% agreement on 37 plateaus (15 of which were considered non readable and 22 readable). When the Pes tracing was added, 100% agreement was reached in 43 out of 91 holds, 13 considered not readable and 30 readable. There was perfect agreement on the Pplat value for the 30 holds which reached universal agreement on readability (0.999 [0.998-1.000] for the tracings with Pes). On average, intra-rater agreement for the 22 Pplat values as scored with and without Pes tracings visible was 0.919. In regards of the duration of the Pplat, the ICC was 0.770 [0.571-0.898] for the tracings without Pes and 0.810 [0.661-0.905] for the tracings with Pes.
CONCLUSION
The interobserver agreement in evaluating inspiratory holds during PSV was relatively low, but when an agreement was reached the interpretation of the value and duration of the plateau were very consistent among raters, as well as the intra-rater agreement in evaluating the same hold with and without Pes. Further analyses are ongoing to evaluate 1)the main reasons for which holds were not uniformly interpreted 2)the features of readable holds.

Image 1
Image 2

1. Driving Pressure Is Associated with Outcome during Assisted Ventilation in Acute Respiratory Distress Syndrome. G. Bellani, A. Grassi, S. Sosio, S. Gatti, B. P. Kavanagh, A. Pesenti, G. Foti. 2019, Anesthesiology, Vol. 131, pp. 594–604.
2. End-Inspiratory Airway Occlusion. A Method To Assess the Pressure Developed by Inspiratory Muscles in Patients with Acute Lung Injury Undergoing Pressure Support. G. Foti, M. Cereda, G. Banfi, P. Pelosi, R. Fumagalli, A. Pesenti. 1997, Am J Respir Crit Care Med, Vol. 156, pp. 1210–1216.
 
Reliability of Inspiratory Holds During Pressure Support Ventilation by Independent Raters Evaluation
Dr. Alice Grassi
Dr. Alice Grassi
CCCF Academy. Grassi A. 10/04/2020; 313833; 75 Topic: Mechanical Ventilation
user
Dr. Alice Grassi
Abstract
Discussion Forum (0)
ePoster
Topic: Safe Ventilation and Oxygenation

Grassi, Alice1; Bianchi, Isabella2; Jonkman, Annemjin3,4; Telias, Irene3; Vieira, Fernando3; Teggia Droghi, Maddalena5; Pham, Tai3; Bellani, Giacomo5; Brochard, Laurent3
1 Department of anesthesiology and pain medicine, University of Toronto, Toronto, Canada
2 Department of critical care and anesthesia, ASST Papa Giovanni XXIII, Bergamo, Italy
3 Interdepartmental division of critical care medicine, University of Toronto, Toronto, Canada
4 Department of Intensive Care Medicine, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
5 School of medicine and surgery, University of Milan-Bicocca, Monza, Italy
Department of Anesthesiology and Pain Medicine, University of Toronto

INTRODUCTION:
Evidence has emerged that driving pressure during pressure support ventilation (PSV) is associated with outcome, as in controlled mechanical ventilation[1]. This measurement, however, is not routinely performed, as it requires a reliable assessment of Plateau Pressure (Pplat) during an inspiratory hold. In fact, not all ventilators allow to perform an inspiratory hold during assisted ventilation modes and the interpretation of the result might not be straightforward because of ongoing patient's muscular activity. Nevertheless, the Pplat value can be of invaluable help in clinical practice, both to compute driving pressure under PSV[1] and to monitor patient's inspiratory effort[2].
OBJECTIVES
To evaluate the reliability in assessing inspiratory holds performed during PSV as general 'readability' (determining if the hold reveals a stable airway Pplat) and as the value and duration of the plateau.
METHODS
This is an ancillary analysis of pressure and flow curves obtained during a multicenter observational study aimed to describe the incidence of patient-ventilator asynchronies in ARDS patients (BEARDS, NCT03447288). Tracings were evaluated by six independent raters, experienced with ventilator waveforms assessment. We selected tracings with an inspiratory hold and a reliable Pes tracing acquired simultaneously. The raters evaluated the same tracing twice, with and without a Pes tracing available, and in random order (Fig1-2). For each tracing, raters were asked to determine the readability of the plateau (readable yes/no) based on the following criteria: 1) flat plateau 2) zero flow 3) in presence of inspiratory efforts, flat plateau before and after the efforts. For the holds considered readable, the value of the plateau and its duration were measured.
Krippendorf's alpha (α) test was used to estimate the interobserver agreement on the general readability of the hold. Intraclass correlation coefficient (ICC) was used to estimate the agreement on continuous variables. α and ICC values >0.75 were considered as good agreement. 
RESULTS
91 tracings (35patients from 11centers) were selected for analysis. The interobserver agreement on the general readability of the hold when evaluating ventilator tracings without Pes available was relatively low (α=0.466 [0.418-0.513]) and increased slightly when Pes tracing was added (α=0.502 [0.458-0.555]). Considering the tracings without Pes, the raters reached an 100% agreement on 37 plateaus (15 of which were considered non readable and 22 readable). When the Pes tracing was added, 100% agreement was reached in 43 out of 91 holds, 13 considered not readable and 30 readable. There was perfect agreement on the Pplat value for the 30 holds which reached universal agreement on readability (0.999 [0.998-1.000] for the tracings with Pes). On average, intra-rater agreement for the 22 Pplat values as scored with and without Pes tracings visible was 0.919. In regards of the duration of the Pplat, the ICC was 0.770 [0.571-0.898] for the tracings without Pes and 0.810 [0.661-0.905] for the tracings with Pes.
CONCLUSION
The interobserver agreement in evaluating inspiratory holds during PSV was relatively low, but when an agreement was reached the interpretation of the value and duration of the plateau were very consistent among raters, as well as the intra-rater agreement in evaluating the same hold with and without Pes. Further analyses are ongoing to evaluate 1)the main reasons for which holds were not uniformly interpreted 2)the features of readable holds.

Image 1
Image 2

1. Driving Pressure Is Associated with Outcome during Assisted Ventilation in Acute Respiratory Distress Syndrome. G. Bellani, A. Grassi, S. Sosio, S. Gatti, B. P. Kavanagh, A. Pesenti, G. Foti. 2019, Anesthesiology, Vol. 131, pp. 594–604.
2. End-Inspiratory Airway Occlusion. A Method To Assess the Pressure Developed by Inspiratory Muscles in Patients with Acute Lung Injury Undergoing Pressure Support. G. Foti, M. Cereda, G. Banfi, P. Pelosi, R. Fumagalli, A. Pesenti. 1997, Am J Respir Crit Care Med, Vol. 156, pp. 1210–1216.
 
ePoster
Topic: Safe Ventilation and Oxygenation

Grassi, Alice1; Bianchi, Isabella2; Jonkman, Annemjin3,4; Telias, Irene3; Vieira, Fernando3; Teggia Droghi, Maddalena5; Pham, Tai3; Bellani, Giacomo5; Brochard, Laurent3
1 Department of anesthesiology and pain medicine, University of Toronto, Toronto, Canada
2 Department of critical care and anesthesia, ASST Papa Giovanni XXIII, Bergamo, Italy
3 Interdepartmental division of critical care medicine, University of Toronto, Toronto, Canada
4 Department of Intensive Care Medicine, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
5 School of medicine and surgery, University of Milan-Bicocca, Monza, Italy
Department of Anesthesiology and Pain Medicine, University of Toronto

INTRODUCTION:
Evidence has emerged that driving pressure during pressure support ventilation (PSV) is associated with outcome, as in controlled mechanical ventilation[1]. This measurement, however, is not routinely performed, as it requires a reliable assessment of Plateau Pressure (Pplat) during an inspiratory hold. In fact, not all ventilators allow to perform an inspiratory hold during assisted ventilation modes and the interpretation of the result might not be straightforward because of ongoing patient's muscular activity. Nevertheless, the Pplat value can be of invaluable help in clinical practice, both to compute driving pressure under PSV[1] and to monitor patient's inspiratory effort[2].
OBJECTIVES
To evaluate the reliability in assessing inspiratory holds performed during PSV as general 'readability' (determining if the hold reveals a stable airway Pplat) and as the value and duration of the plateau.
METHODS
This is an ancillary analysis of pressure and flow curves obtained during a multicenter observational study aimed to describe the incidence of patient-ventilator asynchronies in ARDS patients (BEARDS, NCT03447288). Tracings were evaluated by six independent raters, experienced with ventilator waveforms assessment. We selected tracings with an inspiratory hold and a reliable Pes tracing acquired simultaneously. The raters evaluated the same tracing twice, with and without a Pes tracing available, and in random order (Fig1-2). For each tracing, raters were asked to determine the readability of the plateau (readable yes/no) based on the following criteria: 1) flat plateau 2) zero flow 3) in presence of inspiratory efforts, flat plateau before and after the efforts. For the holds considered readable, the value of the plateau and its duration were measured.
Krippendorf's alpha (α) test was used to estimate the interobserver agreement on the general readability of the hold. Intraclass correlation coefficient (ICC) was used to estimate the agreement on continuous variables. α and ICC values >0.75 were considered as good agreement. 
RESULTS
91 tracings (35patients from 11centers) were selected for analysis. The interobserver agreement on the general readability of the hold when evaluating ventilator tracings without Pes available was relatively low (α=0.466 [0.418-0.513]) and increased slightly when Pes tracing was added (α=0.502 [0.458-0.555]). Considering the tracings without Pes, the raters reached an 100% agreement on 37 plateaus (15 of which were considered non readable and 22 readable). When the Pes tracing was added, 100% agreement was reached in 43 out of 91 holds, 13 considered not readable and 30 readable. There was perfect agreement on the Pplat value for the 30 holds which reached universal agreement on readability (0.999 [0.998-1.000] for the tracings with Pes). On average, intra-rater agreement for the 22 Pplat values as scored with and without Pes tracings visible was 0.919. In regards of the duration of the Pplat, the ICC was 0.770 [0.571-0.898] for the tracings without Pes and 0.810 [0.661-0.905] for the tracings with Pes.
CONCLUSION
The interobserver agreement in evaluating inspiratory holds during PSV was relatively low, but when an agreement was reached the interpretation of the value and duration of the plateau were very consistent among raters, as well as the intra-rater agreement in evaluating the same hold with and without Pes. Further analyses are ongoing to evaluate 1)the main reasons for which holds were not uniformly interpreted 2)the features of readable holds.

Image 1
Image 2

1. Driving Pressure Is Associated with Outcome during Assisted Ventilation in Acute Respiratory Distress Syndrome. G. Bellani, A. Grassi, S. Sosio, S. Gatti, B. P. Kavanagh, A. Pesenti, G. Foti. 2019, Anesthesiology, Vol. 131, pp. 594–604.
2. End-Inspiratory Airway Occlusion. A Method To Assess the Pressure Developed by Inspiratory Muscles in Patients with Acute Lung Injury Undergoing Pressure Support. G. Foti, M. Cereda, G. Banfi, P. Pelosi, R. Fumagalli, A. Pesenti. 1997, Am J Respir Crit Care Med, Vol. 156, pp. 1210–1216.
 

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