Consensus on identifying and ranking ventilator asynchronies in invasively ventilated ICU patients: a modified Delphi study (SYNAPsE)

PURPOSE: Despite extensive research, it remains unclear which patient-ventilator asynchronies are reliably detectable in clinical practice, most clinically relevant, and how they rank in severity. METHODS: Multiple-choice questions and 5-point Likert-scale statements were used in iterative Delphi rounds. Feedback was incorporated until stable consensus or dissensus was reached for all items. First series of rounds focused on identifying and classifying patient-ventilator asynchronies detectable from ventilator waveforms, second series assessed their associations with outcomes in three patient groups, and in the final rounds, asynchronies were ranked by severity within these patient groups and across three scenarios. RESULTS: In total, 11 panelists completed nine rounds. Consensus classified ineffective triggering, reverse triggering, double triggering, auto-triggering, insufficient flow, premature cycling, and delayed cycling as clinically relevant patient-ventilator asynchronies. Of these, auto-triggering and delayed cycling were deemed unlikely to be detectable using ventilator waveforms alone. Across all three patient groups, the panelists reached consensus that double triggering and ineffective triggering were the most clinically relevant. In acute respiratory distress syndrome, double triggering, ineffective triggering, and reverse triggering were all judged clinically relevant. In patients without acute respiratory distress syndrome and after cardiac surgery, asynchronies were classified as severe or mild and combined into two composite groups. CONCLUSION: This Delphi study provides a consensus-based framework for identifying and ranking patient-ventilator asynchronies at the bedside, highlighting those most likely to be clinically relevant and offering a structured approach to support monitoring, intervention, and future research.