Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Review
. 2024 Nov;19(8):2105-2119.
doi: 10.1007/s11739-024-03715-3. Epub 2024 Aug 29.

Monitoring and modulation of respiratory drive in patients with acute hypoxemic respiratory failure in spontaneous breathing

Anna Mocellin #  1 , Federico Guidotti #  1 , Simone Rizzato #  1 , Matteo Tacconi #  1 , Giulia Bruzzi  1 , Jacopo Messina  2 , Daniele Puggioni  1 , Athina Patsoura  1 , Riccardo Fantini  1 , Luca Tabbì  1 , Ivana Castaniere  1 , Alessandro Marchioni  3 , Enrico Clini  1 , Roberto Tonelli  1
Affiliations
Review

Monitoring and modulation of respiratory drive in patients with acute hypoxemic respiratory failure in spontaneous breathing

Anna Mocellin et al. Intern Emerg Med. 2024 Nov.

Abstract

Non-invasive respiratory support, namely, non-invasive ventilation, continuous positive airway pressure, and high-flow nasal cannula, has been increasingly used worldwide to treat acute hypoxemic respiratory failure, giving the benefits of keeping spontaneous breathing preserved. In this scenario, monitoring and controlling respiratory drive could be helpful to avoid patient self-inflicted lung injury and promptly identify those patients that require an upgrade to invasive mechanical ventilation. In this review, we first describe the physiological components affecting respiratory drive to outline the risks associated with its hyperactivation. Further, we analyze and compare the leading strategies implemented for respiratory drive monitoring and discuss the sedative drugs and the non-pharmacological approaches used to modulate respiratory drive during non-invasive respiratory support. Refining the available techniques and rethinking our therapeutic and monitoring targets can help critical care physicians develop a personalized and minimally invasive approach.

Keywords: Acute hypoxemic respiratory failure; Monitoring; Non-invasive respiratory support; Respiratory drive; Sedation.

PubMed Disclaimer

Conflict of interest statement

Declarations. Conflict of interest: RT, RF, LT, IC, AMarchioni, and EC declare patent N. 102021000007478 “APPARATO PER IL RILEVAMENTO ED IL MONITORAGGIO DELLA PRESSIONE NASALE” released on March 28th 2023 by the Italian Ministry of Enterprises and Made in Italy. RT, RF, LT, AMarchioni, and EC are co-founders of IREC ltd (VAT 02959080355) (Reggio Emilia, Italy). RT received travel support and fees from GSK, SEDA, Guidotti, United HealthCare Services. AMocellin, FG, SR, MT, AP, GB, JM, and DP have no competing interests with any organization or entity with a financial interest in competition with the subject, matter, or materials discussed in this manuscript.

Figures

Fig. 1
Fig. 1
Schematic representation of the causes of hyperactivation of the respiratory drive and the pharmacological and non-pharmacological options to control them. This figure represents the vicious cycle that can be triggered by lung damage leading to AHRF. Cortical, biochemical, mechanical, and inflammatory stimuli result in hyperactivation of the respiratory drive, leading to an increase in the mechanical work of respiratory muscles, thus initiating a vicious cycle that culminates in the formation of P-SILI. Non-pharmacological possibilities are mentioned in the pink boxes, while pharmacological options are listed in the green boxes to control this cycle. AHRF acute hypoxemic respiratory failure; P-SILI patient self-inflicted lung injury, PSV pressure support ventilation, ECCO2R extracorporeal carbon dioxide removal
Fig. 2
Fig. 2
Characteristics of the ideal sedative drug
Fig. 3
Fig. 3
“Lung-protective sedation” model. Preliminary assessment: search for signs and symptoms of discomfort and implement non-pharmacological strategies to reduce them. By integrating the preliminary assessment and measuring respiratory drive, it is possible to decide whether sedation is needed or not. If sedation is initiated, it is necessary to achieve the correct level of sedation and control of the respiratory drive through close monitoring. P0.1 Airway occlusion pressure, ΔPes Esophageal pressure swings, ΔPnose Nasal pressure swings, EAdi Diaphragm electrical activity, BPS-NI Behavioral pain scale non-intubated patients, US ultrasound, RSS Ramsay sedation scale, OAA/S observer’s assessment of alertness/sedation, RASS Richmond assessment sedation scale, BIS bispectral index
See this image and copyright information in PMC

References

    1. Ketcham SW, Sedhai YR, Miller HC et al (2020) Causes and characteristics of death in patients with acute hypoxemic respiratory failure and acute respiratory distress syndrome: a retrospective cohort study. Crit Care 24(1):391 - PMC - PubMed
    1. Oczkowski S, Ergan B, Bos L et al (2022) ERS clinical practice guidelines: high-flow nasal cannula in acute respiratory failure. Eur Respir J 59(4):2101574 - PubMed
    1. Grieco DL, Maggiore SM, Roca O et al (2021) Non-invasive ventilatory support and high-flow nasal oxygen as first-line treatment of acute hypoxemic respiratory failure and ARDS. Intensiv Care Med 47(8):851–866 - PMC - PubMed
    1. Qvist J, Pontoppidan H, Wilson RS et al (1975) Hemodynamic responses to mechanical ventilation with PEEP: the effect of hypervolemia. Anesthesiology 42(1):45–55 - PubMed
    1. Bellani G, Laffey JG, Pham T et al (2017) Noninvasive ventilation of patients with acute respiratory distress syndrome. Insights from the LUNG SAFE study. Am J Respir Crit Care Med 195(1):67–77 - PubMed

MeSH terms

LinkOut - more resources