The impact of implementing a patient-ventilator asynchrony (PVA) management protocol on clinical outcomes in ICU patients

doi:10.21203/rs.3.rs-5227654/v1

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Research Article

The impact of implementing a patient-ventilator asynchrony (PVA) management protocol on clinical outcomes in ICU patients

https://doi.org/10.21203/rs.3.rs-5227654/v1

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Background

Mechanical ventilation is a critical life support for ICU patients. However, this intervention can be associated with complications such as patient-ventilator asynchrony (PVA) and subsequent adverse events. This study aimed to investigate the impact of implementing a PVA management protocol on clinical outcomes in ICU patients.

Methods

In this randomized controlled trial conducted in 2023, 66 mechanically ventilated patients admitted to the ICU of a hospital affiliated with Ahvaz Jundishapur University of Medical Sciences, Ahvaz, were randomly assigned to either an intervention or control group. For the intervention group, PVA was assessed twice daily during the morning and evening shifts, and interventions were performed according to the protocol if necessary. The control group did not receive any specific protocol for PVA management. Data were collected using a checklist and analyzed using SPSS version 22.

Results

There was a significant difference between the intervention and control groups in terms of duration of mechanical ventilation (p < 0.001), length of ICU stay (p < 0.001), and successful weaning from the ventilator (p = 0.026). In all three dimensions, the intervention group showed better outcomes. However, there was no significant difference between the two groups in terms of ICU mortality (p = 0.138) or self-extubation (p = 0.85).

Conclusion

The use of a PVA management protocol can lead to positive outcomes such as reduced duration of mechanical ventilation, shorter ICU stay, and increased successful weaning from the ventilator for ICU patients. Given the promising results of this study, it is recommended that this easy-to-implement and cost-effective PVA management protocol be widely adopted in ICU settings. Further research is needed to solidify these findings and explore potential variations in implementation.

Mechanical ventilation

Patient-ventilator asynchrony

fighting the ventilator

Clinical outcomes

Intensive care unit

Mechanical ventilation using a ventilator is one of the most commonly used life support techniques in ICUs worldwide (1–3). Approximately 20 million people globally require the use of ventilators daily for various reasons (4). The primary goal of mechanical ventilation is not to treat lung diseases but to meet the patient's ventilation and oxygenation needs by establishing mechanical ventilation and supporting the lungs until the underlying cause is resolved (5). In fact, the ventilator does not treat the disease; it can only keep the patient alive until the underlying disease is treated (6). Despite being lifesaving, mechanical ventilation can also be associated with many complications for patients, especially those who use it for extended periods (7). Therefore, the ICU treatment and care team always strives to wean patients off the ventilator as soon as the patient's condition allows. However, some patients require the ventilator for several hours, some for several days, and some others for a longer period, even up to several months (8).

Some of the adverse effects of mechanical ventilation include decreased cardiac output, reduced blood flow to vital organs, increased intracranial pressure, gastric distension, tracheoesophageal fistula, increased airway resistance, ventilator-associated pneumonia (VAP), and extreme discomfort for the patient, to name only a few. These complications can increase the length of a patient's stay, delay the recovery process, and increase the mortality rate in the ICU, and even cause complications after weaning from the ventilator and discharge from the ICU (7, 8). These complications will be much more severe and frequent if the ventilator parameters are not properly and correctly adjusted according to the patient's condition and if the treatment and care staff in the ICU do not carefully monitor the mechanical ventilation process (6). Given their duties in this area and the constant presence at the bedside of patients, nurses play a very vital role in monitoring the proper functioning of the ventilator and preventing its complications (9).

One of the significant challenges that can exacerbate the complications of mechanical ventilation is patient-ventilator asynchrony (PVA), sometimes referred to as patient-ventilator fighting (10). This asynchrony occurs when the patient's respiratory efforts are not synchronized with the ventilator. This struggle against the machine is common during intubation and the initiation of mechanical ventilation, often stemming from the expected anxiety in such situations. However, asynchrony developing suddenly in a patient who was previously stable on the ventilator is considered a serious and potentially life-threatening event (11).

The interaction between the patient and the ventilator can be viewed as a relationship between two respiratory pumps: the patient's respiratory system controlled by the neuromuscular system and the ventilator and its associated settings. If these two systems are synchronized, there will be no problem for the patient. Any factor that causes asynchrony between the two systems can lead to patient discomfort, restlessness, and increased work of breathing. This can result in inadequate ventilation, making mechanical ventilation poorly tolerated and causing serious complications (12).

Unfortunately, the incidence of patient-ventilator asynchrony in ICUs is high. For instance, a study by Saghaee et al. in February 2023 in the ICU of an Isfahan hospital revealed a high prevalence of PVA in ventilated patients, especially with volume-controlled modes, and this can prolong the duration of mechanical ventilation (13). In addition, a study by Mirabella et al. (2020) demonstrated a significant incidence of PVA in ICU patients, which can be associated with various complications such as diaphragm dysfunction, sleep disturbances, dyspnea, temporary or permanent neuropsychological changes, and difficult and prolonged weaning from the ventilator (14). Several factors can contribute to asynchrony, including patient characteristics (such as respiratory mechanics, respiratory effort, etc.), ventilator characteristics (mode settings, level of support, cycling criteria, etc.), and the interface used (invasive or non-invasive) (15).

Therefore, careful monitoring and assessment of the patient and ventilator during mechanical ventilation are essential to prevent and manage asynchrony (10). In this regard, the results of several studies have shown that certain interventions can be effective in reducing the incidence of PVA. For example, the results of a study by Moghadasi showed that changing the ventilator mode from volume-controlled to pressure-controlled can be effective in reducing asynchrony between the patient and the ventilator (13).

However, some other studies have stated that using a more comprehensive and systematic protocol for monitoring asynchrony between the patient and the ventilator can yield better results. For instance, a study by Kay Choong See et al. in 2021 found that monitoring the status of patients and the interaction between them and the ventilator twice a day based on a specific protocol reduced mortality and complications related to patient-ventilator asynchrony (15). Also, the results of a systematic review by Kyo et al. in 2021 showed that increased monitoring of the correct interaction between the patient and the ventilator, adjustment of ventilator parameters, and sedative medications can help prevent PVA and its complications. Therefore, it is necessary to evaluate and test various monitoring and systematic methods to achieve the best outcomes (16).

However, currently, in the ICUs of the hospital where this research was conducted, there is no standardized protocol for the correct and timely management of patient-ventilator asynchrony, and the occurrence of this event is often diagnosed incidentally. Therefore, considering the importance of the correct and timely management of patient-ventilator asynchrony and the limited research conducted on this topic, this study aimed to investigate the impact of using a patient-ventilator asynchrony management protocol on clinical outcomes in ICU patients.

Design

The present study is a single blind clinical trial study (Patients were not aware of the assigned group) that was conducted to determine the effect of implementation a protocol for management of patient ventilator asynchrony on clinical outcomes of patients admitted to the ICU of an affiliated Hospital to Jundishapur University of medical science, Ahvaz in 2023.

Population

The sample size was determined based on previous studies (19) with the help of med calc statistical software with a power of 90% and an error of 10%, 60 cases (30 people in each group). Due to the possibility of sample dropout, 10% was added to the above sample size (33 people in each group).

In this study, 66 patients were initially selected using a convenience sampling method based on the inclusion criteria, and they were then randomly assigned to two groups (intervention and control, n = 38 each) using a permuted block randomization method. This was done by selecting 11 blocks of 6 (with equal sizes, including 3 participants in the intervention group and 3 participants in the control group) and then assigning one of the 6 combinations (arranged alphabetically in English) of the two groups in each block.

Inclusion criteria for patients in this study were: informed consent from the legal guardian for the patient's participation in the study, age range between 15 and 65 years, use of mechanical ventilation, less than 1 day of stay in the ICU, APACHE II score between 30 and 40, and having spontaneous respiratory effort in addition to mandatory breaths from the ventilator (patient on assisted-controlled or spontaneous modes). Exclusion criteria included: receiving neuromuscular blocking agents during the study and developing conditions that would cause the patient to be on controlled ventilator modes for a prolonged period (such as brain death).

Intervention:

Patients in the intervention group received twice-daily assessments for patient-ventilator asynchrony (PVA) using a patient-ventilator asynchrony management protocol. When indicated by the protocol, appropriate care and treatment measures were implemented in collaboration with the ICU team, including the bedside nurse and ICU specialist, to address patient-ventilator asynchrony. The control group received routine ward care. Currently, no specific protocol is used to assess PVA in patients admitted to the ICU, and PVA is usually diagnosed incidentally, which can lead to delayed diagnosis and inappropriate care. In addition, the necessary measures to prevent and treat PVA usually include a series of routine measures (such as sedative drug administration without addressing the underlying cause of PVA), which may not be suitable for all patients.

The PVA management protocol used in this study was adapted from a study by Ki Hong et al. (15). This protocol was developed in December 2016 by a multidisciplinary team consisting of medical specialists in this field and a clinical nurse. The protocol's development was informed by a comprehensive review of existing scientific evidence and a rigorous assessment of its practical feasibility in a clinical setting (18, 19). This protocol focuses on identifying common and easily diagnosable causes of ventilator-patient asynchrony. The primary factors contributing to patient-ventilator asynchrony include ineffective respiratory effort, double triggering, and inadequate flow (when the airflow delivered from the device to the patient is insufficient).

To identify these factors, the lead researcher observed patients for 120 seconds during protocol implementation. Observations included monitoring for the use of accessory and abdominal muscles (assessing respiratory effort) and analyzing ventilator waveforms (time-flow and time-pressure curves) to detect asynchronous breathing.

To identify double (or multiple) triggering, any consecutive pair (or group) of breaths was considered an asynchronous breath. The PVA management protocol consists of 6 stages with corresponding actions. If a stage is successful, the next stage is initiated. If the desired outcome (elimination of asynchrony) is not achieved, the process is repeated until the goal is met. Details of the PVA management protocol are presented in Table 1.

Table 1

Patient ventilator asynchrony management protocol
Step Diagnosis	Action
1. Observe patient for 120 s, counting the total number of the following types of asynchronous breaths: Ineffective efforts Double triggering Inadequate flow	Document the following in the notes: date, time, presence of ineffective efforts. Presence of double triggering, presence of inadequate flow breaths. Document ventilator changes in the notes. If total asynchronous breaths < 3: Go to Step 6. If total asynchronous breaths 3: Go to Steps 2–4.
2. For ineffective efforts	Check and management airway obstruction. Adjust sedation, aiming for RASS 0 to 2. Adjust flow trigger to 2 L/min. Measure intrinsic PEEP and apply appropriate external PEEP
3. For double triggering	Increase tidal volume to maximum of 8 ml/kg ideal body weight. Increase respiratory rate to maximum of 30 breaths per minute. Change to pressure assist-control and increase inspiratory time to achieve an inspiratory-to-expiratory ratio of no more than 1. If all fails, deepen sedation, aiming to eliminate the inspiratory drive (aim for RASS − 4 to 5) while underlying disease is being treated.
4. For inadequate flow	Increase inspiratory flow to maximum of 80 L/min. Change to pressure assist-control and adjust pressure to limit VT to maximum of 8 ml/kg ideal body weight Try proportional assist ventilation, adjusting support level to limit tidal volume to maximum of 8 ml/kg ideal body weight
5. Observe patient for 120 s, counting the total number of the following types of asynchronous breaths: Ineffective efforts Double triggering Inadequate flow	Document the following in the notes: date, time, presence of ineffective efforts Presence of double triggering, presence of inadequate flow. Document ventilator change in the notes. If total asynchronous breaths < 3: Go to Step 6. If total asynchronous breaths 3: Go to Steps 2e4.
6. Check extubation plan	If plan is not for extubation: Do nothing. If plan is for extubation o Inform nurses to wean off sedation, aiming for RASS − 2 to 0. o Once RASS − 2 to 0 achieved, and if not already done, change to pressure support or proportional assist ventilation and commence weaning/spontaneous breathing trials.

Data collection method and tools

Data collection involved a two-section form. The first section captured patient demographics and background information (age, sex, admission diagnosis, APACHE II score) through chart review and interviews with family members and the bedside nurse. The second section of the form captured clinical outcomes, including ICU length of stay, ventilator duration, mortality, successful weaning, and spontaneous extubation. These data were collected by the research assistant through chart review.

In this study, the APACHE II score was used to assess the severity of illness upon admission to the ICU. Developed by Knaus in 1985, APACHE II incorporates 12 physiologic variables to represent major physiological systems (17). According to the standard APACHE II table, mortality rates for patients with scores of 0–15, 16–19, 20–30, and greater than 30 are approximately 10%, 15%, 35%, and 75%, respectively (20). APACHE II is a globally recognized standard tool widely used in studies in Iran (21) and worldwide (22–24) to determine the severity of illness in ICU patients, with established reliability and validity. Solaimani et al. reported a Cronbach's alpha of 0.89 for the reliability of this tool (25).

Statistical analysis:

In this study, descriptive and analytical statistical analysis methods were used in SPSS software (version 22, SPSS Inc., Chicago, IL, USA). Quantitative variables were reported as mean, standard deviation, and minimum and maximum, and qualitative variables were reported as frequency (percentage). The normality of quantitative variables was assessed using the Shapiro–Wilk test. Independent t-test, independent samples t-test (To compare the mean of continuous variables in two group) and Chi-square test (To compare nonparametric variables in two group) were used to data analysis. The statistical significance level was considered to be 0.05.

A total of 66 patients were included in this study, and their data was subjected to statistical analysis (Fig. 1). The mean age of the participants in both groups was 48.42 ± 15.20 years, the mean GCS score upon admission was 6.92 ± 1.45, and the mean APACHE score was 33.84 ± 2.90. Of all participants, 25 (37.9%) were female and 41 (62.1%) were male. In terms of admission diagnosis, 35 patients (53%) were admitted to the ICU due to trauma and 31 (47%) due to medical conditions. There were no significant differences between the two groups in terms of demographic and baseline variables (Table 2).

Table 2

Baseline Patient Characteristics
Variable		Group		Total	P value
Variable		Intervention	Control	Total	P value
Age Mean (SD)		43.18 (15.24)	47.78 (15.36)	42.48 (15.20)	0..370
Initial GCS Mean (SD)		6.87 (.1.59)	6.96 (1.31)	6.92 (1.45)	0..801
APACHE Mean (SD)		33.60(2.86)	34.09(2.97)	33.84(2.90)	0.502
Cause of Brain Injury N (%)	trauma	20 (30.3)	15 (22.7)	35(53.0)	0.218
Cause of Brain Injury N (%)	Internal problems	13 (19.7)	18 (27.3)	31 (47.0)	0.218
Gender N (%)	Male	21 (31.8)	20 (30.3)	41 (62.1)	0..80
Gender N (%)	Female	12 (18.2)	13 (19.7)	25 (37.9)	0..80

A total of 714 cases of patient-ventilator asynchrony were identified and recorded for the intervention group. The most common type of asynchrony was ineffective respiratory effort, accounting for 43.83% of cases (Table 3).

Table 3

Type of patient-ventilator asynchrony in the intervention group
Type asynchronous	N (%)	Total
Insufficient flow N (%)	263 (36.83)	714
Double stimulation N (%)	138 (19.32)
Ineffective respiratory effort N (%)	313 (43.83)

Chi-square test results showed no significant difference in ICU mortality between the control and intervention groups (p = 0.399). A total of 12 patients (18.18%) from both groups passed away in the ICU. Chi-square test results also showed no significant difference in the incidence of self-extubation between the control and intervention groups (p = 0.587), with a total of 19 patients (28.78%) experiencing self-extubation. However, chi-square test results showed a significant difference between the intervention and control groups in terms of successful weaning from the ventilator (p = 0.026), with a higher rate in the intervention group (Table 4).

Table 4

Comparing the two groups in terms of occurrence Death IN ICU; Self extubation; Successful weaning
Variable	Group		situation		Total	X²	Df	P value^b
Variable	Group		Happened	not happen	Total	X²	Df	P value^b
Death in ICU	Intervention	n	4	29	33	0.216	1	0.339
	Intervention	% within ID	12.12	87.88	100
	Control	n	8	25	33
	Control	% within	24.24	75.76	100
	Total	n	12	54	66
	Total	% within ID	18.18	81.81	100
Self extubation	Group		situation		Total	0.294	1	0.587
	Group		yes	no	Total
	Intervention	n	8	25	33
	Intervention	% within ID	24.24	75.76	100
	Control	n	11	22	33
	Control	% within	33.33	66.66	104.7
	Total	n	19	47	66
	Total	% within ID	28.78	71.21	100
Successful weaning	Intervention	n	20	13	33	0.048	1	0.026
	Intervention	% within ID	60.6	39.4	100
	Control	n	11	22	33
	Control	% within	33.3	66.7	100
	Total	n	31	35	66
	Total	% within ID	47.0	53.0	100

Independent t-test results showed a significant difference between the intervention and control groups in terms of the number of days spent in the ICU (p < 0.001), with a mean of 34.63 ± 6.37 days in the control group and 19.45 ± 8.19 days in the intervention group. Furthermore, independent t-test results showed a significant difference between the two groups in terms of the duration of mechanical ventilation (p < 0.001), with a mean of 31.42 ± 42.01 days in the control group and 16.15 ± 15.22 days in the intervention group (Table 5).

Table 5

Comparing the two groups regarding response variables
	Group	n	Mean	SD	Total Mean (SD)	t		P value
Duration of ICU hospitalization	Intervention	33	19	8.45	26.81 (9.63)	5.874	64	0.001
Duration of ICU hospitalization	Control	33	34.63	12.74	26.81 (9.63)	5.874	64	0.001
Duration of ventilator connection	Intervention	33	16.15	9.22	23.78(11.42)	5.794	64	0.001
Duration of ventilator connection	Control	33	31.42	12.01	23.78(11.42)	5.794	64	0.001

The mean age of patients in this study was 42.48 years, which is expected given that most of the study participants were trauma patients. In a study by Yong Fang Zhou et al. (2019), the mean age was reported as 64 years. In their study, age was identified as a risk factor for adverse clinical outcomes in mechanically ventilated patients (42). Similarly, in a study by Si et al. (2021), the mean age of patients was reported as 61 years (15). However, what is consistent across these studies and the present study is that PVA management can be effective for all age groups.

The majority of participants (62.1%) in this study were male, which could be attributed to the fact that trauma patients comprised 53% of the sample, and the incidence of trauma is higher in males. In Fang Zhou et al., the number of female and male patients was 292 and 384, respectively (26). Si et al. observed a similar distribution of gender with 62% male and 38% female participants, and their results showed no significant association between gender and the incidence of PVA (15). In Saghaee (2023), male patients accounted for 57.1% of the participants, and their results showed that changing from volume-controlled ventilation to pressure-controlled ventilation was effective in reducing asynchrony for all patients, regardless of gender (13). Therefore, based on the results of these studies and those of the present study, it can be concluded that PVA management can be effective for both males and females.

In this study, the mean severity of illness score (APACHE II) was reported as 33.84 ± 2.90, and there was no significant difference between the two groups in this regard. In Si et al., the APACHE II score was reported as 27.1 ± 8.5 (15). A higher APACHE II score is associated with an increased likelihood of PVA and adverse clinical outcomes such as prolonged mechanical ventilation (20). Therefore, it can be argued that selecting a similar range of APACHE II scores for inclusion in the present study was appropriate for a more accurate evaluation of the intervention results.

This study showed that the most common cause of PVA was ineffective and inefficient respiratory efforts, accounting for an average of 69.7%, while the least common cause was double-triggering, with an average of 9.1%. In a study by De Haro et al. (2018), ineffective and inefficient respiratory efforts were also identified as the most common cause of PVA (10). Similarly, Blanche et al. (27) reported ineffective respiratory effort as the most common cause of patient-ventilator asynchrony. Based on these results, it can be concluded that efforts to eliminate ineffective respiratory efforts and increase respiratory muscle strength are key strategies for managing and eliminating PVA.

The results of the present study showed that although the incidence of self-extubation was lower in the intervention group (42.1%) compared to the control group (57.9%), the difference between the two groups was not statistically significant. Consistent with this result, De Haro (10) suggested that managing and preventing PVA does not have a direct impact on reducing self-extubation. Based on the results of the present study, it can be argued that in a study with a larger sample size, the effect of implementing a PVA protocol on the rate of self-extubation might become significant. However, it should be noted that many factors can affect the occurrence of self-extubation, such as agitation and restlessness, pain, and problems related to the endotracheal tube (e.g., cuff leak), which need to be addressed along with the elimination of patient-ventilator asynchrony to reduce the rate of self-extubation.

Results of the current study showed that there was no significant difference in mortality rates between the two groups in the ICU, which is consistent with the results of Fang Zhou et al. who reported no significant association between the implementation of a PVA protocol and mortality rates in ICU patients (26). However, contrary to these results, Si et al. (15) found that implementing a screening and management protocol for patient-ventilator asynchrony was associated with a significant 15% reduction in hospital mortality. Similarly, the results of a study by Rodis Megranz et al. (28) demonstrated a significant correlation between the occurrence of patient-ventilator asynchrony and increased mortality rates in ICU patients. There could be several reasons for the discrepancy in the results of this study regarding the impact of the intervention on mortality rates in the ICU compared to the aforementioned studies. Factors such as sample size, different study methodologies (for example Si et al. (15) was a retrospective cohort study with a longer duration), as well as differences in patients' clinical conditions, ICU environments, healthcare teams, diagnoses, etc., could contribute to these variations. However, given the positive results of the mentioned studies regarding the positive impact of implementing a PVA protocol, as well as the results of the present study regarding the positive impact of this protocol on length of stay, mechanical ventilation, and successful weaning, it can be argued that the implementation of a PVA management and diagnosis protocol is likely to have a positive impact on reducing mortality rates in patients. Since all of these factors can directly or indirectly affect mortality rates in ICU patients, it is necessary to conduct more comprehensive studies on this topic in the future.

The results of the current study showed that the rate of successful weaning from the ventilator was higher in the intervention group compared to the control group. Consistent with these findings, Michihito (2021) reported a positive impact of implementing a PVA protocol on successful weaning from the ventilator (16). Also, the results of Saghaee et al. (13) showed that PCV modes, compared to VCV modes, reduced asynchrony between the patient and the ventilator, which could increase the chance of successful patient weaning from the ventilator. Furthermore, the results of the study by Si et al. (15) showed that implementing a PVA management protocol twice daily was associated with an increase in successful weaning of patients from the ventilator. Therefore, based on the results of the present study and the aforementioned studies, it can be concluded that patient-ventilator asynchrony is one of the main and influential factors in successful patient weaning from the ventilator, and proper management of this problem can significantly contribute to better weaning of patients from the ventilator.

The results of the present study indicated that the mean length of stay in the ICU was shorter in the intervention group compared to the control group. Consistent with this result, a study by Zhou (26) stated that managing and trying to eliminate PVA reduces the length of patient stay in the ICU. Similarly, Saghaee et al. (13) showed that the average length of stay in the ICU decreased from 10 days to 7 days after efforts to eliminate PVA. Si et al. (15) also found that the average number of days of ICU stay decreased from 12.5 days before implementing the PVA management protocol to 9 days after implementing this protocol. Therefore, although many factors can affect the length of a patient's stay in the ICU, it should be stated that based on the results of the present study and the aforementioned similar studies, the occurrence of PVA is also one of these main factors that can directly or indirectly increase the length of a patient's stay in the ICU.

The study results showed that the average length of stay in the ICU was shorter in the intervention group compared to the control group. Similarly, Si et al. (15) found that using a PVA management protocol reduced the duration of mechanical ventilation. Rodis Megranz (28) also reported that patients with more asynchronies were on mechanical ventilation for an average of 3 days longer. The results of a study by Blanche et al. (27) also showed that patients with an asynchrony index greater than 10% were on mechanical ventilation for a longer average duration. In Saghaee et al. (13), changing from volume-controlled ventilation to pressure-controlled ventilation to reduce asynchronies led to a decrease in the duration of mechanical ventilation. The results of De Haro (10) also indicated that patients with high asynchrony were on mechanical ventilation for an average of 5.16 days longer. Therefore, based on the results of the present study and similar studies, it can be concluded that PVA is one of the main causes of increased duration of ventilator use and poor clinical outcomes, and proper management can reduce the duration of ventilation and improve patient outcomes.

The results of this study demonstrated that using a standardized protocol for managing patient-ventilator asynchrony can lead to positive outcomes such as a reduction in the duration of mechanical ventilation and length of stay in the ICU, and an increased chance of successful weaning from the ventilator for ICU patients. Therefore, based on the results obtained in this study, it can be suggested that this protocol (which is easy to implement, cost-effective, and has no specific side effects) be taught to all ICU nurses, and arrangements be made for its implementation. Further research is needed to solidify these findings and explore potential variations in implementation.

ICU

Intensive care unit

PVA

patient-ventilator asynchrony

APACHE

Acute physiology and chronic health evaluation

Ethics approval and consent to participate

This study was approved by the Research Ethics Committee of Ahvaz Jundishapur University of Medical Sciences (ethics code: IR.AJUMS.REC.1402.472). Also, the present study was registered on 2023-12-08 with clinical trial code; IRCT20231001059572N1 in the Iranian Registry of Clinical Trials (irct.ir). Ethical considerations were in accordance with the Helsinki Declaration 1995, revised 2001. The aim and method of the study were explained to the family member of patients and their questions were answered by the first researcher. Family members and their patient could withdraw from the study at any time without any effect on the caring process of patient. The written informed consent form was signed by family member (patient's legal guardian) who willingly agreed to take part patient in this study. The confidentiality and anonymity of patient information were ensured throughout the study process. Each participant was assigned a unique ID number to protect her identity, and the listing that linked the participant to the ID number was kept separate from the questionnaires.

Consent for publication
Not applicable.

Competing interests
All authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Author details

1Nursing Care Research Center in Chronic Diseases, School of Nursing and Midwifery, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.

2Pain Research Center, Ahvaz Jundishapur University of Medical Sciences,Ahvaz, Iran. 3Department of Epidemiology and Biostatistics, School of Public Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.

FUNDING

The author(s) disclosed receipt of the following financial support for the research, authorship, and publication of this article: This work was supported by the Research Deputy of Ahvaz Jundishapur University of Medical Sciences (grant number U-02367).

Author Contribution

Study conception and design: "M A, M R, M S"- Data collection: "M A, MR" - Data analysis and interpretation: "MA, S GH"- Drafting of the manuscript: "All authors"- Critical revision of the manuscript: "M A, MR"

ACKNOWLEDGMENTS

The present study was part of a Master's degree dissertation in nursing approved and funded by Ahvaz Jundishapur University of Medical Sciences. We hereby thank all patients and their families, the nurses, and all individuals who cooperated in implementing this project in one way or another

Availability of data and materials

Data may be available by request submitted to the corresponding author

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The impact of implementing a patient-ventilator asynchrony (PVA) management protocol on clinical outcomes in ICU patients

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Version 1

The impact of implementing a patient-ventilator asynchrony (PVA) management protocol on clinical outcomes in ICU patients

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

Background

Methods

Design

Population

Intervention:

Data collection method and tools

Statistical analysis:

Results

Discussion

Conclusion

Abbreviations

Declarations

Ethics approval and consent to participate

Consent for publication Not applicable.

Competing interests All authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Author details

FUNDING

Author Contribution

ACKNOWLEDGMENTS

Availability of data and materials

References

Additional Declarations

Status:

Version 1

Consent for publication
Not applicable.

Competing interests
All authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.