Safe titration of pressure-support ventilation: Balancing patient effort, drive, and ventilator assistance: Safe titration of pressure-support ventilation

Chakorn Lapanan; Nattaya Raykateeraroj; Nuanprae Kitisin

doi:10.54205/ccc.v34.278750

Authors

Chakorn Lapanan Department of Intensive Care, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand, 10700 https://orcid.org/0009-0005-7883-910X
Nattaya Raykateeraroj Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand, 10700 https://orcid.org/0000-0002-1212-2115
Nuanprae Kitisin Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand, 10700 https://orcid.org/0000-0001-9703-3551

DOI:

https://doi.org/10.54205/ccc.v34.278750

Keywords:

Diaphragm, Patient–ventilator interaction, Pressure-support ventilation, Pro-portional assist ventilation, Respiratory drive, Respiratory muscles, Lung and diaphragm protective ventilation

Abstract

Pressure-support ventilation (PSV) is commonly used for invasive weaning and assisted ventilation. However, bedside titration often relies on tidal volume and rate rather than direct indices of respiratory drive and inspiratory effort, risking over- or under-assistance with downstream diaphragm dysfunction, asynchrony, and lung stress. This narrative review synthesized a physiology-guided approach to safe PSV titration and proposed practical bedside guidance for intensivists adjusting trigger sensitivity, rise time, pressure-support level, and cycling to maintain synchrony while targeting a moderate, sustainable patient effort. Practical monitoring included airway pressure-based measures, including airway occlusion pressure at 100 ms (P0.1), end-expiratory occlusion pressure (Pocc), and the pressure muscle index (PMI), as well as esophageal manometry, diaphragm electrical activity (EAdi), and diaphragm ultrasound thickening fraction (TFdi). Integrating these tools promotes an “adequate assistance” zone in which tidal volume (VT) and respiratory rate remain stable across modest PS changes and effort is neither suppressed nor excessive. Proportional modes, such as neurally adjusted ventilatory assist (NAVA) and proportional assist ventilation plus (PAV+), can enhance interaction by scaling support to immediate effort, but physiology-based assessment remains central to individualized, lung- and diaphragm-protective ventilation during PSV.

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Safe titration of pressure-support ventilation: Balancing patient effort, drive, and ventilator assistance