What causes the distortions of pressure and flow during the second breath?
Answer: Reverse triggering. This refers to a diaphragmatic muscle contractions triggered by ventilator insufflations. The patient in this case was highly sedated and ventilated in volume-control mode. The second mechanical insufflation was triggered by the ventilator, inducing an inspiratory muscle contraction that can be seen from the decrease in esophageal pressure (vertical dotted line). This inspiratory effort was sufficient to trigger another breath, resulting in double inspiration with a large tidal volume.
Akoumianaki E, Lyazidi A, Rey N, Matamis D, Perez-Martinez N, Giraud R, Mancebo J, Brochard L, Richard JM. Mechanical ventilation-induced reverse-triggered breaths: a frequently unrecognized form of neuromechanical coupling. Chest 2013;143:927-938.
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