Accuracy of Invasive and Noninvasive Parameters
for Diagnosing Ventilatory Overassistance During
Pressure Support Ventilation
Renata Pletsch-Assuncao, RT, PhD1; Mayra Caleffi Pereira, RT, MSc1; Jeferson George Ferreira, RT1,2;
Letícia Zumpano Cardenas, RT, PhD1,2; André Luis Pereira de Albuquerque, MD, PhD1,3;
Carlos Roberto Ribeiro de Carvalho, MD, PhD1; Pedro Caruso, MD, PhD1,2
Objective: Evaluate the accuracy of criteria for diagnosing pres-
sure overassistance during pressure support ventilation.
Design: Prospective clinical study.
Setting: Medical-surgical ICU.
Patients: Adults under mechanical ventilation for 48 hours or more
using pressure support ventilation and without any sedative for 6
hours or more. Overassistance was defined as the occurrence of
work of breathing less than 0.3 J/L or 10% or more of ineffective
inspiratory effort. Two alternative overassistance definitions were
based on the occurrence of inspiratory esophageal pressure-time
product of less than 50 cm H2O s/min or esophageal occlusion
pressure of less than 1.5 cm H2O.
Interventions: The pressure support was set to 20 cm H2O and
decreased in 3-cm H2O steps down to 2 cm H2O.
Measurements and Main results: The following parameters were
evaluated to diagnose overassistance: respiratory rate, tidal vol-
ume, minute ventilation, peripheral arterial oxygen saturation, rapid
shallow breathing index, heart rate, mean arterial pressure, change
1
Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas,
­Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
2
Intensive Care Unit, AC Camargo Cancer Center, São Paulo, Brazil.
3
Sírio-Libanês Teaching and Research Institute, São Paulo, Brazil.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Work was performed at the Heart Institute (InCor), Hospital das Clínicas,
Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
Supported and funded by Fundação de Amparo a Pesquisa do Estado de
São Paulo (Fapesp) (2012/09170-3 and 2010/08947-9), a governmental
nonprofit agency. No restrictions were placed on authors regarding the
statements made in the manuscript.
Dr. de Albuquerque received support for article research from FAPESP
- Fundação de Amparo à Pesquisa do Estado de São Paulo, and he dis-
closed government work. The remaining authors have disclosed that they
do not have any potential conflicts of interest.
For information regarding this article, E-mail: pedro.caruso@hc.fm.usp.br
Copyright © 2017 by the Society of Critical Care Medicine and Wolters
Kluwer Health, Inc. All Rights Reserved.
DOI: 10.1097/CCM.0000000000002871
Critical Care Medicine www.ccmjournal.org 1
Copyright © 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
in ­esophageal pressure during inspiration, and esophageal and air-
way occlusion pressure. In all definitions, the respiratory rate had the
greatest accuracy for diagnosing overassistance (receiver operat-
ing characteristic area = 0.92; 0.91 and 0.76 for work of breath-
ing, pressure-time product and esophageal occlusion pressure in
definition, respectively) and always with a cutoff of 17 incursions per
minute. In all definitions, a respiratory rate of less than or equal to 12
confirmed overassistance (100% specificity), whereas a respiratory
rate of greater than or equal to 30 excluded overassistance (100%
sensitivity).
Conclusion: A respiratory rate of 17 breaths/min is the parameter
with the greatest accuracy for diagnosing overassistance. Respi-
ratory rates of less than or equal to 12 or greater than or equal to
30 are useful clinical references to confirm or exclude pressure
support overassistance. (Crit Care Med 2017; XX:00–00)
Keywords: data accuracy; diagnosis; pressure support ventilation;
respiration, artificial/methods; respiration, artificial/utilization; work
of breathing
N
o precise guidelines are available for bedside adjust-
ment of pressure support during pressure support
ventilation (PSV); therefore, bedside adjustment is
not as easy as envisaged previously (1). Additionally, studies
about the adjustment of the level of pressure support have
focused on the risk of offering insufficient pressure support
(underassistance) because unloading the respiratory muscle is
one of the major objectives of mechanical ventilation (2, 3).
The adjustment of the level of pressure support during PSV is
still a developing issue needing further investigation.
Adequate pressure support during PSV has not yet been
defined, probably because few studies have been performed
about excessive pressure support during PSV (overassistance)
and because it is difficult to recognize and diagnose subtle
underassistance. Previous studies that evaluated underassis-
tance initially measured noninvasive variables, such as min-
ute volume (4–6), tidal volume (4, 5), respiratory rate (4, 5),
vital capacity (6), recruitment of accessory inspiratory muscles
Pletsch-Assuncao et al
(5, 7, 8), and patient comfort (9), but these variables had little
accuracy for diagnosing underassistance. Other variables, such
as work of breathing (WOB) (5, 6), esophageal occlusion pres-
sure (P0.1es) (4, 8) and diaphragmatic electromyography (10)
were evaluated and had greater accuracy, but at the cost of
invasiveness and less suitability to bedside use.
Although overassistance may be frequent during PSV
(11–15), it has not received the same attention as underassis-
tance, and to our knowledge, no study has evaluated the occur-
rence, diagnosing, and risk factors of overassistance during PSV.
The probable reasons for that absence are that most patients
receiving overassistance look comfortable, and the complica-
tions, such as mechanical ventilation prolongation (16), occur
later or are difficult to perceive, such as ventilator-induced
lung injury (17, 18), hyperinflation (19), diaphragmatic atro-
phy and dysfunction (20), patient-ventilator asynchrony
(14–16), and sleep disorders (21). Although overassistance
may be frequent and has many hazardous adverse effects, there
are no criteria for diagnosing overassistance during PSV.
The primary objective of the present study was to test the
accuracy of invasive and noninvasive criteria for diagnosing
overassistance during PSV. The secondary objective was to
quantify the occurrence of overassistance during PSV.
METHODS
For further details, see supplementary material (Supplemen-
tal Digital Content 1, http://links.lww.com/CCM/D56).
Study Design
This was a prospective crossover study conducted in a medical
ICU of a tertiary teaching hospital (Respiratory ICU - Hospital
das Clinicas de São Paulo, Brazil). The study was approved by
the local Ethics Committee (0835/11), and a signed informed
consent was obtained from next of kin.
Patients
Patients were eligible during the first 48 hours of the transition
from a controlled mode (volume or pressure-controlled venti-
lation) to PSV and were consecutively recruited. The ICU had
no protocol to guide the transit from the controlled mode to
an assisted mode of mechanical ventilation, so that transition
was at the discretion of the attending team.
Inclusion criteria were age 18 years old or older, mechani-
cal ventilation for 48 hours or more, and absence of any sedative
drugs for 6 hours or more. Patients were excluded if they had a
previous neuromuscular disease, a decreased level of consciousness
(Richmond Agitation Sedation Scale score of –3, –4, or –5) or had
been considered for withdrawal or withholding of life support.
At ICU admission, we recorded the demographic character-
istics, reason for ICU admission, reason for mechanical venti-
lation, and the Simplified Acute Physiology Score.
Monitoring and Variables Recorded
Immediately after patient inclusion, a pneumotachograph
(MLT3813H-V; Hans Rudolph, Shawnee, KS), an esopha-
geal, and a gastric air-filled balloon catheter (CooperSurgical,
2 www.ccmjournal.org XXX 2017 • Volume XX • Number XXX
Copyright © 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Trumbull, CT) were inserted. A T-piece was inserted between
the ventilator y-connector and the ventilator circuit (Three-way
T-Shape Stopcock-Type, 2130 Series; Hans Rudolph, Shawnee,
KS) to allow proximal airway pressure monitoring and manual
occlusions. During the protocol, we continually recorded the fol-
lowing variables: proximal airway pressure, esophageal pressure,
gastric pressure, and airway flow. The peripheral arterial oxygen
saturation, heart rate, and systolic and diastolic pressures were
continuously monitored and recorded from the multiparamet-
ric monitor. Initially, we recorded the variables over 20 minutes,
keeping the ventilator as adjusted by the attending team (base-
line). After the baseline period, the oxygen inspiratory fraction,
trigger sensitivity, positive end-expiratory pressure (PEEP), and
cycling-off criteria were maintained as adjusted by the attending
team, but the level of pressure support was set to 20 cm H2O and
decreased in 3-cm H2O steps down to 2 cm H2O (20, 17, 14, 11,
8, 5, and 2 cm H2O). At all pressure support levels, we recorded
all variables during a 20-minute period. At any pressure sup-
port level, the protocol could be interrupted before the end of
the 20-minute period if the patient had signs of respiratory dis-
tress, defined as the appearance of at least one of the following
signs: heart rate 140 or more beats/min, increased basal respira-
tory rate of 50% or more, hypotension (systolic blood pressure
< 90 mm Hg) or hypertension (systolic blood pressure > 180 mm
Hg), use of accessory respiratory muscles, cardiac arrhythmia,
diaphoresis, agitation, appearance of abdominal or thoracic par-
adoxical movements, and peripheral arterial oxygen saturation
of less than or equal to 90%.
At the end of each 20-min period or when the patient had
showed signs of respiratory distress, we performed five non-
consecutive airway occlusion maneuvers with 30- to 60-second
intervals between them. From the occluded cycles, we measured
esophageal (P0.1es) and proximal airway (P0.1aw) occlusion pres-
sure (4, 22–24) and averaged the values of the five measures.
Data were acquired through an analog to digital converter
(ADS 1000; Lynx Eletronica, São Paulo, Brazil) connected to a
personal computer running software designed to acquire the
data (AqDados 7.2; Lynx Eletronica). Data were analyzed off-line
using customized software (Labview 7.1; National Instruments,
Austin, TX). For each pressure support level, the Labview soft-
ware calculated a representative mean cycle through point-­by-
point averaging of all included respiratory cycles.
The mean proximal airway pressure, airway flow tidal
volume, minute ventilation, respiratory rate, and gastric and
esophageal pressures were calculated from the last 2 minutes of
the 20-minute period or when the patient had signs of respira-
tory distress. The inspiratory WOB was calculated using the
Campbell diagram (25) and represented the sum of the inspi-
ratory resistive flow and elastic WOB. The WOB was expressed
as J per liter. The inspiratory esophageal pressure-time product
(PTPes) was calculated by the integration of esophageal pres-
sure over inspiratory time, assuring that expiratory pressures
were excluded from the analysis of inspiratory PTPes (26, 27).
PTPes was multiplied by the respiratory rate and expressed as
cm H2O s/min (28).

We identified ineffective inspiratory effort by visual inspec-
tion of esophageal and proximal airway pressure of the
2-­minute period used to calculate all variables. The percentage
of ineffective inspiratory effort was calculated as the number
of ineffective efforts divided by the total respiratory rate com-
puted as the sum of the number of ventilator cycles and inef-
fective efforts.
Definition of Overassistance and Underassistance
Pressure support overassistance was defined as the occur-
rence of one or more of the following two variables: WOB less
than 0.3 J/L (29, 30) or 10% or more of ineffective inspiratory
efforts (9, 31). Furthermore, we tested two alternative defini-
tions. The first alternative definition was based on the occur-
rence of one or more of the following variables: PTPes less than
50 cm H2O s/min (14, 27, 32) or 10% or more of ineffective
inspiratory efforts. The second alternative definition was based
on the occurrence of one or more of the following variables:
P0.1es less than 1.5 cm H2O (4, 22–24) or 10% or more of inef-
fective inspiratory efforts.
Pressure support underassistance was defined by the occur-
rence of at least one of the following signals of respiratory
distress: heart rate 140 or more beats/min, increase in the
respiratory rate of 50% or more of basal (respiratory rate was
defined as the sum of the respiratory rate indicated by the ven-
tilator and the rate of ineffective inspiratory efforts), hypoten-
sion (systolic blood pressure < 90 mm Hg) or hypertension
(systolic blood pressure > 180 mm Hg), use of accessory respi-
ratory muscles, cardiac arrhythmia, diaphoresis, agitation,
appearance of abdominal or thoracic paradoxical movements,
and peripheral arterial oxygen saturation of 90% or less.
Statistical Analysis
The categorical variables are presented as percentages. The
continuous variables are presented as mean ± SD or median
and 25–75% interquartile range (IQR), as appropriate.
We tested the accuracy of the following noninvasive criteria
for diagnosing overassistance: respiratory rate, tidal volume,
minute ventilation, peripheral arterial oxygen saturation, rapid
shallow breathing index (33) (respiratory rate divided by the
mean tidal volume in liters), P0.1aw (4, 34), heart rate, and mean
arterial pressure. We also tested the accuracy of the following
invasive criteria: P0.1es and the change in esophageal pressure
during inspiration (ΔPes).
Standard formulas were used to calculate sensitivity, speci-
ficity, and positive and negative predictive values. A positive
result was defined as a test that diagnosed overassistance when
overassistance truly happened. The predictive performance of
each criterion was evaluated using the area under the curve of
a receiver operating characteristic (ROC) curve. The optimal
cutoff value for each criterion was calculated using Youden’s
index (35). The ROC area under the curve of each criterion
was compared using the DeLong test (36).
The occurrence of overassistance at each pressure support
level was tested with chi-square test. The trend of each single
variable over the different pressure support levels was tested
Critical Care Medicine www.ccmjournal.org 3
Copyright © 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Clinical Investigation
Figure 1. Flow chart of patients screened for the study.
using linear regression. The statistical analysis was performed
using SPSS 20.0 software (IBM, Armonk, NY), and a p value of
less than or equal to 0.05 was considered significant.
The study followed the Standards for Reporting of
Diagnostic Accuracy Studies guidelines (37).
RESULTS
Thirty-five consecutive patients were eligible and 27 were
included (Fig. 1 and Table 1). Two hundred and eleven obser-
vations of different pressure support levels were analyzed. In
24 patients, it was possible to test all pressure support levels (20
to 2 cm H2O) without interruption. However, due to respira-
tory distress, one patient stopped at 11 cm H2O, two at 5 cm
H2O, and five at 2 cm H2O (Table E1, Supplemental Digital
Content 2, http://links.lww.com/CCM/D57; and Table E2, Sup-
plemental Digital Content 3, http://links.lww.com/CCM/D58).
In the 211 pressure support levels observed, using WOB, PTPe
or P0.1es in definition, overassistance was present in 96 (45.5%),
116 (59.7%), and 102 observations (48.3%), respectively.
At baseline, the median pressure support level was
8.0 cm H2O (7.0–8.0 cm H2O, IQR) and using WOB, PTPe or
P0.1es in definition, overassistance was diagnosed in 10 (37%),
13 (48%), and 12 patients (44%), respectively. At the high-
est pressure support levels (17 or 20 cm H2O), overassistance
occurred in 75–90% of the patients, but decreased steadily and
significantly with the pressure decrease (p < 0.01 for all overas-
sistance definitions) (Fig. 2).
The most frequent criteria for diagnosing overassistance
were depicted in Table E3 (Supplemental Digital Content 4,
http://links.lww.com/CCM/D59). The percentage of ineffec-
tive inspiratory efforts was 7% at baseline, increased to more
than 15% at 20 cm H2O, and then decreased significantly with
the decrease in the pressure support (Fig. E1, Supplemental
Digital Content 5, http://links.lww.com/CCM/D60).
The following parameters varied significantly over the dif-
ferent pressure support levels: respiratory rate, tidal volume,
index of rapid shallow breathing, P0.1aw, P0.1es, change in esopha-
geal pressure during inspiration (ΔPes), whereas minute ventila-
tion, peripheral arterial oxygen saturation, heart rate, and mean
Pletsch-Assuncao et al

TABLE 1. Demographic and Clinical

Characteristics of the Patients
Patient Characteristics n = 27

Age (yrs) (± sd) 60 ± 16

Male (%) 12 (44)
Ideal weight (kg) 55 ± 10
Body mass index (kg/m ) 2
24 ± 5
Simplified Acute Physiology Score 3 at ICU 60 ± 19
admission
Reasons for ICU admittance (%)
 Pneumonia 7 (25.9)
  Septic shock 7 (25.9)
  Interstitial lung disease exacerbation 4 (14.8)
  Acute respiratory distress syndrome 3 (11.1) Figure 2. Occurrence of overassistance at each pressure support level.
P0.1es = esophageal occlusion pressure, PTP = inspiratory esophageal
  Chronic obstructive pulmonary disease 3 (11.1) pressure-time product, WOB = inspiratory work of breathing.
exacerbation
  Cardiogenic shock 2 (7.5) and positive predict value of 100% to diagnose overassistance.
Complementarily, a respiratory rate of 26 ipm or more (WOB
  After cardiopulmonary arrest 1 (3.7) in definition), 25 ipm or more (PTP in definition), or 30 ipm
Reasons for mechanical ventilation (%) or more (P0.1es in definition) had a sensitivity and negative
  Hypoxemic respiratory failure 18 (66.7) predict value of 100% to exclude overassistance.
Using WOB in definition, following the respiratory rate,
  Hypercapnic respiratory failure 9 (33.3) other parameters with a high ROC area were the rapid shallow
Richmond Agitation Sedation Scale sedation breathing index, P0.1a and P0.1es (Table 2 and Fig. 3). Using PTP
scale during protocol (%) in definition, following the respiratory rate, other parameters
 –2 4 (14.8) with a high ROC area were the rapid shallow breathing index
and P0.1aw. Finally, using P0.1es in definition, following the respi-
 –1 9 (33.3)
ratory rate, other parameters with a high ROC were the rapid
 0 11 (40.7) shallow breathing index and heart rate (Table 2 and Fig. 3).
 1 3 (11.1)
No. of ICU days until protocol initiation 7 (3–18) DISCUSSION
Total ICU length of stay (d) 18 (6–36) In the present study, we showed that a respiratory rate of 17
ipm was the best parameter to diagnose pressure overassistance
Invasive mechanical ventilation duration (d) 11 (4–29) during PSV. We also showed that in our sample, the occurrence
Reintubation rate (%) 4 (14.8) of overassistance was around 40%.
ICU mortality (%) 8 (29.7)
The Definition of Overassistance
To our knowledge, there are no former definitions of over-
arterial pressure did not vary significantly over the different assistance, probably due to the lack of understanding of the
pressure support levels (Fig. E2, Supplemental Digital Content issue. Due to the absence of an overassistance definition, our
6, http://links.lww.com/CCM/D61). As expected, the chosen challenge was to develop one. Ideally, the overassistance defini-
criteria used to define overassistance varied significantly over tion should be based on relevant clinical outcomes like mor-
the different pressure support levels (Fig. E3, Supplemental tality, duration of mechanical ventilation, and hospital length
Digital Content 7, http://links.lww.com/CCM/D62). of stay; however, no previous studies supported that task. As a
surrogate, we based our overassistance definition on physio-
Accuracy of Parameters to Diagnose Overassistance pathologic outcomes like WOB, PTPes, P0.1es, or the occurrence
In all definitions, the ROC area under the curve of the respi- of ineffective inspiratory effort.
ratory rate was significantly higher than the area of all other
evaluated parameters and always with a cutoff value of The Literature About Overassistance Is Scarce
17 incursions per minute (ipm) (Table 2 and Fig. 3). In all The literature about pressure support titration during
definitions, a respiratory rate of 12 ipm or less had a specificity PSV has been focused on underassistance (1). This focus is

4 www.ccmjournal.org XXX 2017 • Volume XX • Number XXX

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 Clinical Investigation

TABLE 2. Cutoff Values, Area Under the ROC Curve, Sensitivity, Specificity, Positive
Predictive Value, and Negative Predictive Value of All Criteria Used to Diagnose
Overassistance
Receiver Operator Positive Negative
Characteristics Area Sensitivity Specificity Predictive Predictive
Criterion Cutoff Under the Curve (%) (%) Value (%) Value (%)

Work of breathing in the definition

  Respiratory rate (ipm) 17 0.92 (0.89–0.96) 90 (83–95) 82 (74–89) 81 91
  RSBI (ipm/L) 37 0.84 (0.79–0.90) 72 (62–80) 89 (81–94) 85 79
 P0.1 airway (cm H2O) 1.6 0.82 (0.76–0.88) 62 (52–72) 87 (79–93) 80 73
 P0.1 esophageal (cm H2O) 2.1 0.81 (0.76–0.87) 84 (76–91) 65 (55–74) 67 83
  Δ esophageal pressure (cm H2O) 7.3 0.75 (0.69–0.82) 62 (52–72) 79 (70–86) 71 71
 VT (mL/ideal weight) 9.0 0.71 (0.64–0.78) 67 (57–76) 73 (63–80) 68 72
  Heart rate (bpm) 91 0.66 (0.59–0.74) 61 (51–71) 67 (57–76) 61 67
 VE (L/min) 10.3 0.63 (0.56–0.71) 79 (70–86) 50 (40–60) 57 74
 Spo2 (%) 94 0.62 (0.55–0.70) 71 (61–80) 52 (42–62) 56 67
  MAP (mmHg) 83 0.58 (0.51–0.66) 44 (34–53) 71 (61–79) 56 60
Pressure-time-product in the definition
  Respiratory rate (ipm) 17 0.91 (0.87–0.95) 80 (72–87) 87 (78–93) 90 74
  RSBI (ipm/L) 37 0.83 (0.77–0.88) 63 (54–71) 92 (84–97) 92 62
 P0.1 airway (cm H2O) 2.3 0.75 (0.68–0.82) 80 (71–86) 64 (52–74) 77 67
  Δ esophageal pressure (cm H2O) 9.5 0.75 (0.69–0.82) 73 (64–81) 69 (58–79) 78 63
 P0.1 esophageal (cm H2O) 2.1 0.74 (0.68–0.81) 79 (70–85) 64 (53–74) 77 67
 VT (mL/ideal weight) 8.5 0.68 (0.61–0.76) 66 (59–74) 65 (54–76) 74 56
 VE (L/min) 10.3 0.65 (0.57–0.72) 75 (67–83) 54 (43–65) 71 59
 Spo2 (%) 94 0.64 (0.56–0.71) 69 (60–77) 55 (44–66) 70 54
  Heart rate (bpm) 92 0.62 (0.54–0.70) 63 (54–72) 62 (51–73) 72 53
  MAP (mmHg) 108 0.54 (0.46–0.62) 89 (82–94) 21 (13–31) 63 56
P0.1 esophageal in the definition
  Respiratory rate (bpm) 17 0.76 (0.69–0.82) 78 (69–86) 70 (61–79) 71 78
  Heart rate (bpm) 91 0.66 (0.59–0.74) 64 (54–73) 64 (54–73) 62 66
  RSBI (ipm/L) 36 0.65 (0.57–0.72) 54 (44–64) 74 (65–82) 66 64
 VE (L/min) 10.3 0.63 (0.56–0.71) 76 (67–84) 49 (39–58) 58 69
  MAP (mmHg) 93 0.63 (0.56–0.71) 79 (70–87) 45 (35–55) 57 70
 VT (mL/ideal weight) 9.1 0.58 (0.50–0.66) 53 (43–63) 66 (56–75) 59 60
 Spo2 (%) 92 0.52(0.44–0.60) 78 (69–86) 28 (20–38) 50 59
Δ = delta, bpm = beats/min, cm H2O = centimeters of water, ipm = incursions per minute, MAP = mean arterial pressure, P0.1 = occlusion pressure,
RBSI = rapid shallow breathing index (respiratory rate over tidal volume in liters), Spo2 = peripheral saturation of oxygen, VE = minute volume, VT = tidal volume.
Between parentheses is the 95% CI.

probably because the occurrence of underassistance is obvi-
ous with oxygen arterial desaturation, respiratory distress,
agitation, diaphoresis, and many other unsubtle signals, but
the occurrence of overassistance is subtle and easily con-
founded by comfort because overassistance is expressed by a
low respiratory rate, high tidal volume, and absence of sym-
pathetic nervous system activation. In addition to the evident
difference in the clinical picture, overassistance probably
did not garner attention because its complications are dif-
ficult to diagnose or to associate with overassistance, such as

Critical Care Medicine www.ccmjournal.org 5

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Pletsch-Assuncao et al

Figure 3. Receiver operating characteristic (ROC) curve of respiratory rate, rapid shallow breathing index, and esophageal (P0.1es) and proximal airway
(P0.1aw) occlusion pressure. Work of breathing (WOB) in definition (left graphic): ROC area of respiratory rate was significantly higher than the area of the
other parameters (p < 0.01 for the three comparisons). Rapid shallow breathing index vs P0.1es (p = 0.44); rapid shallow breathing index vs P0.1aw
(p = 0.60); P0.1aw vs P0.1es (p = 0.30). Pressure-time product in definition (center graphic): ROC area of respiratory rate was significantly higher than the
area of the other parameters (p < 0.01 for the three comparisons). Rapid shallow breathing index vs P0.1es (p = 0.07); rapid shallow breathing index vs
P0.1aw (p = 0.10); and P0.1aw vs P0.1es (p = 0.47). P0.1es in definition (right graphic): ROC area of respiratory rate was significantly higher than the area of the
other parameters (p <0.01 for rapid shallow breathing index and p = 0.02 for heart rate). p = 0.71 for rapid shallow breathing index vs heart rate.
P0.1es, P0.1aw, and change in esophageal pressure were not tested because P0.1es was in the definition of overassistance.

mechanical ventilation prolongation (16), ventilator-induced
lung injury (17, 18), hyperinflation (19), diaphragmatic atro-
phy and dysfunction (20), patient-ventilator asynchrony
(14–16), and sleep disorders (21).
Previous studies have suggested that the occurrence of over-
assistance is high, but they did not quantify it (11, 38). In the
present study, at baseline, overassistance occurred in 37–48%
of the patients, depending on the definition. Although, to our
knowledge, no previous study has evaluated the occurrence
and diagnosis of overassistance during PSV, many articles have
evaluated the best adjustment of pressure support during PSV
(4–6, 8, 9, 39). These studies included different populations,
used different methods to find the best PSV adjustment, and
aimed to evaluate mainly underassistance. In these articles,
respiratory rate and P0.1es were the more relevant accurate
parameters to adjust the PSV, which is in accordance with our
results.
Clinical Relevance
The avoidance of overassistance is important to patients
receiving mechanical ventilation, because as mentioned pre-
viously, overassistance is associated with severe mechanical
ventilation-induced complications, such as mechanical venti-
lation prolongation (16), ventilator-induced lung injury (17,
18), hyperinflation (19), diaphragmatic atrophy and dysfunc-
tion (20), patient-ventilator asynchrony (14–16), and sleep
disorders (21). To avoid treatment complications, the first
step is awareness of the problem; we believe that the present
study sheds light on the problem. After awareness, the sec-
ond step is the capability to diagnose the complications and
again we believe that the present study provides knowledge of
the invasive and noninvasive parameters that can be used to
diagnose overassistance. We showed that independently of the
definition, a respiratory rate of 12 breaths/min or less confirms
overassistance (100% sensitivity), whereas a respiratory rate
of 30 or more excludes overassistance (100% sensibility). We
believe that the description of these upper and lower bounds
can be useful clinical references in daily practice.
Limitations
Our study has limitations. First, it was performed at a single
center. Our ICU is in a teaching hospital dedicated exclusively to
respiratory care and admits patients with different respiratory
diseases, so other ICUs with different patient or professional
profiles may have a different percentage of overassistance. Sec-
ond, as mentioned previously in the Discussion section, our
definitions of overassistance might have influenced the results;
however, we tested three different definitions based on solid
physiologic knowledge and the results were similar because a
respiratory rate of 17 was the predictor with higher accuracy
in all definitions. Third, although at the beginning of the pro-
tocol, no patient was considered to a spontaneous breathing
test by the attending team, 70% of patients tolerated a pressure
support of 2 cm H2O, signaling that they were able to a sponta-
neous breathing test. That discrepancy between the capability
of the patients and the perception of spontaneous breathing
test readiness by the physicians was previously described (40,
41). Fourth, our population was composed of hypercapnic
and hypoxemic patients and it is possible that those subgroups
respond differently to overassistance. A final limitation is that
we did not randomize the different pressure support levels, but
we applied a descending order of the pressure support. We used
that strategy on purpose because we wanted to avoid the pos-
sibility that an initial underassistance could cause deteriora-
tion in clinical condition and respiratory muscle fatigue, even
a high-frequency fatigue that would hinder the continuation

6 www.ccmjournal.org XXX 2017 • Volume XX • Number XXX

Copyright © 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

of the evaluation. In fact, other studies have used the same
descending order, probably to avoid the same problems (4).
In conclusion, excessive pressure support during PSV is
frequent. In nonsedated or lightly sedated patients in pres-
sure support ventilation, a respiratory rate of 17 ipm is the
parameter with the greatest accuracy for diagnosing overassis-
tance and respiratory rates of 12 or less or 30 or more are use-
ful clinical references to confirm or exclude pressure support
overassistance.
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