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Pressure support ventilation (PSV) should allow spontaneous breathing with a “normal” neuro-ventilatory drive. Low neuro-ventilatory drive puts the patient at risk of diaphragmatic atrophy while high neuro-ventilatory drive may causes dyspnea and patient self-inflicted lung injury. We continuously assessed for 12 h the electrical activity of the diaphragm (EAdi), a close surrogate of neuro-ventilatory drive, during PSV. Our aim was to document the EAdi trend and the occurrence of periods of “Low” and/or “High” neuro-ventilatory drive during clinical application of PSV.Method  In 16 critically ill patients ventilated in the PSV mode for clinical reasons, inspiratory peak EAdi peak (EAdi PEAK ), pressure time product of the trans-diaphragmatic pressure per breath and per minute (PTP DI/b  and PTP DI/min , respectively), breathing pattern and major asynchronies were continuously monitored for 12 h (from 8 a.m. to 8 p.m.). We identified breaths with “Normal” (EAdi PEAK  5–15 μV), “Low” (EAdi PEAK  < 5 μV) and “High” (EAdi PEAK  > 15 μV) neuro-ventilatory drive.    Results  Within all the analyzed breaths (177.117), the neuro-ventilatory drive, as expressed by the EAdi PEAK , was “Low” in 50.116 breath (28%), “Normal” in 88.419 breaths (50%) and “High” in 38.582 breaths (22%). The average times spent in “Low”, “Normal” and “High” class were 1.37, 3.67 and 0.55 h, respectively ( p  < 0.0001), with wide variations among patients. Eleven patients remained in the “Low” neuro-ventilatory drive class for more than 1 h, median 6.1 [3.9–8.5] h and 6 in the “High” neuro-ventilatory drive class, median 3.4 [2.2–7.8] h. The asynchrony index was significantly higher in the “Low” neuro-ventilatory class, mainly because of a higher number of missed efforts.Conclusions  We observed wide variations in EAdi amplitude and unevenly distributed “Low” and “High” neuro ventilatory drive periods during 12 h of PSV in critically ill patients. Further studies are needed to assess the possible clinical implications of our physiological findings.

Continuous assessment of neuro-ventilatory drive during 12 h of pressure support ventilation in critically ill patients