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Background  Ineffective triggering is frequent during pressure support ventilation (PSV) and may persist despite ventilator adjustment, leading to refractory asynchrony. We aimed to assess the effect of proportional assist ventilation with load-adjustable gain factors (PAV+) on the occurrence of refractory ineffective triggering.    Design  Observational assessment followed by prospective cross-over physiological study.    Setting  Academic medical ICU.    Patients  Ineffective triggering was detected during PSV by a twice-daily inspection of the ventilator’s screen. The impact of pressure support level (PSL) adjustments on the occurrence of asynchrony was recorded. Patients experiencing refractory ineffective triggering, defined as persisting asynchrony at the lowest tolerated PSL, were included in the physiological study.    Interventions  Physiological study: Flow, airway, and esophageal pressures were continuously recorded during 10 min under PSV with the lowest tolerated PSL, and then under PAV+ with the gain adjusted to target a muscle pressure between 5 and 10 cmH 2 O.    Measurements  Primary endpoint was the comparison of asynchrony index between PSV and PAV+ after PSL and gain adjustments.    Results  Among 36 patients identified having ineffective triggering under PSV, 21 (58%) exhibited refractory ineffective triggering. The lowest tolerated PSL was higher in patients with refractory asynchrony as compared to patients with non-refractory ineffective triggering. Twelve out of the 21 patients with refractory ineffective triggering were included in the physiological study. The median lowest tolerated PSL was 17 cmH 2 O [12–18] with a PEEP of 7 cmH 2 O [5–8] and FiO 2  of 40% [39–42]. The median gain during PAV+ was 73% [65–80]. The asynchrony index was significantly lower during PAV+ than PSV (2.7% [1.0–5.4] vs .  22.7% [10.3–40.1],  p  < 0.001) and consistently decreased in every patient with PAV+. Esophageal pressure–time product (PTPes) did not significantly differ between the two modes (107 cmH 2 O/s/min [79–131] under PSV vs .  149 cmH 2 O/s/min [129–170] under PAV+,  p  = 0.092), but the proportion of PTPes lost in ineffective triggering was significantly lower with PAV+ (2 cmH 2 O/s/min [1–6] vs .  8 cmH 2 O/s/min [3–30],  p  = 0.012).    Conclusions  Among patients with ineffective triggering under PSV, PSL adjustment failed to eliminate asynchrony in 58% of them (21 of 36 patients). In these patients with refractory ineffective triggering, switching from PSV to PAV+ significantly reduced or even suppressed the incidence of asynchrony.    Supplementary Information  The online version contains supplementary material available at 10.1186/s13613-021-00935-0.

Refractory ineffective triggering during pressure support ventilation: effect of proportional assist ventilation with load-adjustable gain factors