Abstract
<title>Abstract</title> <p> <bold>Background.</bold> The performance of intentional-leak single-limb and dual-limb turbine-driven ventilators versus dual-limb compressed-gas pediatric ventilators has not been systematically evaluated during noninvasive ventilation (NIV) in pediatric respiratory failure. We therefore conducted a randomized crossover physiological study to compare patient-ventilator interaction across these three ventilator configurations in infants with acute respiratory failure. <bold>Methods.</bold> In this single-center, randomized, crossover physiological study each infant underwent three 30-minute NIV phases, in randomized order, with constant ventilator settings: intentional-leak single-limb turbine ventilator (SLC-Turbine), dual-limb turbine ventilator (DLC-Turbine) with active expiratory valve, and dual-limb compressed-gas pediatric ventilator (DLC-PICU). Esophageal pressure was used to assess patient-ventilator interaction (Asynchrony Index [AI] and individual asynchrony events). The primary end point was the difference in AI between DLC-PICU and SLC-Turbine, and the secondary end point the difference in AI between DLC-PICU and DLC-Turbine. Breathing pattern and respiratory effort were explored by comparing the three ventilator configurations with unassisted spontaneous breathing. <bold>Results.</bold> Twenty infants entered the stabilization phase, 13 were randomized, and 12 completed the crossover protocol and were analyzed (age 10 [7–21] months; SpO₂/FiO₂ 185 [160–220]). AI differed significantly across configurations (7.5% [0–13.7], 16.8% [7.6–25], and 34.2% [17.4–67] with SLC-Turbine, DLC-Turbine, and DLC-PICU, respectively; p=0.0001). AI was higher with DLC-PICU than with SLC-Turbine (primary end point: HL +33.0, 95% CI +23.5 to +41.6; p=0.0001) and than with DLC-Turbine (secondary end point: HL +24.2, 95% CI +15.4 to +32.7; p=0.0001). Ineffective efforts did not differ across configurations. Auto-triggering was significantly higher with DLC-PICU than with SLC-Turbine (4 [0-12.5] vs 0 [0-0] events/min; p=0.0001), whereas it did not differ between DLC-PICU and DLC-Turbine. Late cycling was significantly more frequent with DLC-PICU than with SLC-Turbine (0 [0-10] vs 0 [0-0] events/min; p=0.002), whereas no significant difference was observed between DLC-PICU and DLC-Turbine. Despite marked differences in patient–ventilator synchrony, respiratory muscle effort was similar across the three configurations, with no difference between SLC-Turbine and DLC-PICU in esophageal pressure swing (7.6 vs 7 cmH₂O; p=0.540) or esophageal pressure–time product (180 vs 135 cmH₂O·s·min⁻¹; p=0.898). <bold>Conclusions.</bold> Compared with the compressed-gas pediatric ICU ventilator, both turbine configurations improved patient-ventilator interaction, with the single-limb configuration providing the greatest reduction in asynchrony. <bold>Clinical trial registration</bold> . ClinicalTrials.gov, NCT04017780. Enrolment was originally planned to start in 2019 but was postponed because of the COVID-19 pandemic; patients were subsequently enrolled between January 2022 and December 2025. </p>