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Buyse B, Kalkanis A, Testelmans D. Catathrenia in severe obstructive sleep apnea: A novel entity never described before. Sleep Med 2023; 112:239-245. [PMID: 37925850 DOI: 10.1016/j.sleep.2023.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 10/12/2023] [Accepted: 10/20/2023] [Indexed: 11/07/2023]
Abstract
STUDY OBJECTIVES Catathrenia, derived from the Greek κατά (kata) meaning below and θρηνώ (threnia) to lament, is characterized by expiratory groaning episodes during sleep. In a case series of nine patients with severe obstructive sleep apnea, we observed a peculiar groaning entity that has not been described before. METHODS We described and illustrated the cases with polysomnographic tracings and additional audio recordings. RESULTS All patients were men, obese (body mass index 39 ± 6 kg/m2) with an apnea-hypopnea index ranging from 47 to 125/h. In addition, we identified groaning events that were consistently preceded by a cortical arousal associated with a "rescue" respiration after an obstructive hypopnea or apnea. These events exhibited characteristics of "mixed apnea's", but the "central apnea-like part" was a prolonged expiratory groaning phase, with immediately after the terminal expiratory snort appearance of an obstructive apnea. In case the duration of this expiration was at least 10 s we calculated these events separately and the index was 8.4 ± 7.7/h. More rarely (index 0.6 ± 0.5/h) a "central apnea mimicking event" with groaning not followed by an obstruction, was observed. We also observed groaning episodes during expiration with a shorter duration (less than 10 s), not calculated separately. Positive airway pressure, which was well tolerated, eliminated these events. CONCLUSIONS This novel catathrenia entity preceded by a cortical arousal and "rescue" respiration in response to obstructive events is intriguing. Possible explanations for these observations are further discussed in this article.
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Affiliation(s)
- Bertien Buyse
- Department of Pulmonology, Leuven University Center for Sleep and Wake Disorders (LUCS), University Hospitals Leuven Campus Gasthuisberg, Leuven, Belgium; Laboratory of Respiratory Disease and Thoracic Surgery (BREATH), KU Leuven-University, Leuven, Belgium.
| | - Alexandros Kalkanis
- Department of Pulmonology, Leuven University Center for Sleep and Wake Disorders (LUCS), University Hospitals Leuven Campus Gasthuisberg, Leuven, Belgium
| | - Dries Testelmans
- Department of Pulmonology, Leuven University Center for Sleep and Wake Disorders (LUCS), University Hospitals Leuven Campus Gasthuisberg, Leuven, Belgium; Laboratory of Respiratory Disease and Thoracic Surgery (BREATH), KU Leuven-University, Leuven, Belgium
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2
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Baglyas S, Valkó L, Móró V, Podmaniczky E, Czövek D, Makan G, Gingl Z, Gál J, Hantos Z, Lorx A. Using intra-breath oscillometry in obesity hypoventilation syndrome to detect tidal expiratory flow limitation: a potential marker to optimize CPAP therapy. BMC Pulm Med 2023; 23:477. [PMID: 38017501 PMCID: PMC10685591 DOI: 10.1186/s12890-023-02777-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/21/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Continuous positive airway pressure (CPAP) therapy has profound effects in obesity hypoventilation syndrome (OHS). Current therapy initiation focuses on upper airway patency rather than the assessment of altered respiratory mechanics due to increased extrapulmonary mechanical load. METHODS We aimed to examine the viability of intra-breath oscillometry in optimizing CPAP therapy for OHS. We performed intra-breath oscillometry at 10 Hz in the sitting and supine positions, followed by measurements at increasing CPAP levels (none-5-10-15-20 cmH2O) in awake OHS patients. We plotted intra-breath resistance and reactance (Xrs) values against flow (V') and volume (V) to identify tidal expiratory flow limitation (tEFL). RESULTS Thirty-five patients (65.7% male) completed the study. We found a characteristic looping of the Xrs vs V' plot in all patients in the supine position revealing tEFL: Xrs fell with decreasing flow at end-expiration. Intra-breath variables representing expiratory decrease of Xrs became more negative in the supine position [end-expiratory Xrs (mean ± SD): -1.9 ± 1.8 cmH2O·s·L- 1 sitting vs. -4.2 ± 2.2 cmH2O·s·L- 1 supine; difference between end-expiratory and end-inspiratory Xrs: -1.3 ± 1.7 cmH2O·s·L- 1 sitting vs. -3.6 ± 2.0 cmH2O·s·L- 1 supine, p < 0.001]. Increasing CPAP altered expiratory Xrs values and loop areas, suggesting diminished tEFL (p < 0.001). 'Optimal CPAP' value (able to cease tEFL) was 14.8 ± 4.1 cmH2O in our cohort, close to the long-term support average of 13.01(± 2.97) cmH2O but not correlated. We found no correlation between forced spirometry values, patient characteristics, apnea-hypopnea index and intra-breath oscillometry variables. CONCLUSIONS tEFL, worsened by the supine position, can be diminished by stepwise CPAP application in most patients. Intra-breath oscillometry is a viable method to detect tEFL during CPAP initiation in OHS patients and tEFL is a possible target for optimizing therapy in OHS patients.
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Affiliation(s)
- Szabolcs Baglyas
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1082 Üllői út 78/B, Budapest, Hungary.
| | - Luca Valkó
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1082 Üllői út 78/B, Budapest, Hungary
| | - Vivien Móró
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1082 Üllői út 78/B, Budapest, Hungary
| | - Eszter Podmaniczky
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1082 Üllői út 78/B, Budapest, Hungary
| | - Dorottya Czövek
- Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Gergely Makan
- Department of Technical Informatics, University of Szeged, Szeged, Hungary
| | - Zoltán Gingl
- Department of Technical Informatics, University of Szeged, Szeged, Hungary
| | - János Gál
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1082 Üllői út 78/B, Budapest, Hungary
| | - Zoltán Hantos
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1082 Üllői út 78/B, Budapest, Hungary
| | - András Lorx
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1082 Üllői út 78/B, Budapest, Hungary
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Brekka AK, Vollsæter M, Ntoumenopoulos G, Clemm HH, Halvorsen T, Røksund OD, Andersen TM. Adjustments of non-invasive ventilation and mechanically assisted cough by combining ultrasound imaging of the larynx with transnasal fibre-optic laryngoscopy: a protocol for an experimental study. BMJ Open 2022; 12:e059234. [PMID: 35613803 PMCID: PMC9134209 DOI: 10.1136/bmjopen-2021-059234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Application of non-invasive positive airway pressure may provoke laryngeal responses that obstruct the airways, especially in patients with disturbed laryngeal control. To control and adjust for this, transnasal fibre-optic laryngoscopy (TFL) is used to visualise laryngeal movements during therapeutic interventions. Being an invasive procedure, this may be unpleasant for patients. The aim of this study is to evaluate if ultrasound (US) imaging of the larynx may be used as an alternative less invasive diagnostic tool for evaluating the upper airway responses to non-invasive ventilation (NIV) and mechanical insufflation-exsufflation (MI-E). METHODS AND ANALYSIS This protocol presents an experimental cross-sectional study of a novel method to study laryngeal responses in adult healthy volunteers (n=30). The participants will be assessed with simultaneous TFL and laryngeal US imaging (anterior and lateral approaches) during NIV and MI-E therapy. Additionally, airflow and pressure signals will be registered during the procedures. The primary outcome is whether laryngeal US is a feasible method to study laryngeal responses and, if so, to compare the laryngeal responses visualised with TFL and US. The participants' perception of the examinations will be recorded. Secondary outcomes include airflow curve shapes and calculated ventilation volumes during the interventions. ETHICS AND DISSEMINATION The study has been approved by The Regional Committee for Medical Research Ethics in Norway, and registered in ClinicalTrials.gov. Results will be disseminated through peer-reviewed journals, presentation of scientific abstracts at international medical conventions and oral presentations in relevant medical conventions. TRIAL REGISTRATION NUMBER NCT04586855.
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Affiliation(s)
| | - Maria Vollsæter
- Norwegian Advisory Unit on Home Mechanical Ventilation, Haukeland University Hospital, Bergen, Norway
- Faculty of Medicine, Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - George Ntoumenopoulos
- Department of Physiotherapy, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
| | - Hege Havstad Clemm
- Faculty of Medicine, Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Thomas Halvorsen
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Ola Drange Røksund
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
- The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Tiina Maarit Andersen
- Norwegian Advisory Unit on Home Mechanical Ventilation, Haukeland University Hospital, Bergen, Norway
- The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
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Ueha R, Maeda E, Ino K, Shimizu T, Sato T, Goto T, Yamasoba T. Sleep-Induced Glottis Closure in Multiple System Atrophy Evaluated by Four-Dimensional Computed Tomography. Front Med (Lausanne) 2020; 7:132. [PMID: 32363195 PMCID: PMC7180743 DOI: 10.3389/fmed.2020.00132] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 03/26/2020] [Indexed: 12/20/2022] Open
Abstract
Multiple system atrophy (MSA) is a progressive neurodegenerative disorder. Since patients with MSA often have sleep-related respiratory disorders including upper-airway obstruction and/or central sleep disturbance, appropriate evaluation of the upper airway especially during sleep may be indispensable. Fiberoptic laryngoscopy during diazepam-induced sleep has been reported for upper-airway obstruction verification. However, some patients cannot endure the uncomfortable sensation of the fiberscope. To address these issues, we devised a protocol of four four-dimensional computed tomography (4D-CT) for upper-airway evaluation during sleep. Here, we report the case of patient with MSA who was evaluated for upper-airway obstruction during sleep using 4D-CT. A 46-year-old man (height 1.60 m, weight 79 kg) was admitted to our neurological department for tracheal intubation because of a sudden onset of respiratory failure occurring at night. At the age of 45 years, he was diagnosed as MSA with predominant parkinsonism. As pulmonary disease had been excluded and his swallowing was normal, our differential diagnoses were central sleep apnea or obstructive sleep apnea related to his MSA or obstructive sleep apnea (SA) related to his obesity. A tracheostomy was done to maintain the airway after extubation. Polysomnography showed obstructive SA and not central SA. Awake fiberoptic laryngoscopy showed no upper airway obstruction but bilateral vocal abduction impairment (BVAI) during inspiration. To assess the spatial and temporal conditions of the upper respiratory tract—the patient could not tolerate sleep laryngoscopy—we carried out a 4D-CT. Reconstructed 4D-CT images of respiration during sleep showed clear abnormalities: glottis closure at the terminal stage of inspiration and subsequent velopharyngeal closure. As glottis closure does not occur normally in obesity patients, the cause of the respiratory failure in this patient was considered MSA-related sleep-induced airway obstruction. We decided to keep the tracheostoma, because BVAI in patients with MSA may be getting worse, although central apnea after tracheostomy may cause sudden central origin-related death; 4 months postoperatively, the patient had experienced no further airway-related complications. This report indicates that 4D-CT sequential upper-airway assessment during sleep is useful for determining the abnormalities causing obstructive SA in patients with MSA.
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Affiliation(s)
- Rumi Ueha
- Department of Otolaryngology, The University of Tokyo, Tokyo, Japan
| | - Eriko Maeda
- Department of Computational Diagnostic Radiology and Preventive Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Kenji Ino
- Department of Computational Diagnostic Radiology and Preventive Medicine, The University of Tokyo Hospital, Tokyo, Japan.,Imaging Center, The University of Tokyo Hospital, Tokyo, Japan
| | | | - Taku Sato
- Department of Otolaryngology, The University of Tokyo, Tokyo, Japan
| | - Takao Goto
- Department of Otolaryngology, The University of Tokyo, Tokyo, Japan
| | - Tatsuya Yamasoba
- Department of Otolaryngology, The University of Tokyo, Tokyo, Japan
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Jounieaux V, Rodenstein DO. Glottic patency during noninvasive ventilation in patients with chronic obstructive pulmonary disease. Respir Physiol Neurobiol 2019; 259:178. [DOI: 10.1016/j.resp.2018.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 09/06/2018] [Indexed: 10/28/2022]
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Aarrestad S, Qvarfort M, Kleiven AL, Tollefsen E, Skjønsberg OH, Janssens JP. Diagnostic accuracy of simple tools in monitoring patients with chronic hypoventilation treated with non-invasive ventilation; a prospective cross-sectional study. Respir Med 2018; 144:30-35. [DOI: 10.1016/j.rmed.2018.09.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 09/24/2018] [Accepted: 09/25/2018] [Indexed: 12/14/2022]
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Oppersma E, Doorduin J, Gooskens PJ, Roesthuis LH, van der Heijden EHFM, van der Hoeven JG, Veltink PH, Heunks LMA. Glottic patency during noninvasive ventilation in patients with chronic obstructive pulmonary disease. Respir Physiol Neurobiol 2018; 259:53-57. [PMID: 30026086 DOI: 10.1016/j.resp.2018.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 07/13/2018] [Accepted: 07/16/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Non-invasive ventilation (NIV) provides ventilatory support for patients with respiratory failure. However, the glottis can act as a closing valve, limiting effectiveness of NIV. This study investigates the patency of the glottis during NIV in patients with acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD). METHODS Electrical activity of the diaphragm, flow, pressure and videolaryngoscopy were acquired. NIV was randomly applied in pressure support (PSV) and neurally adjusted ventilatory assist (NAVA) mode with two levels of support. The angle formed by the vocal cords represented glottis patency. RESULTS Eight COPD patients with acute exacerbation requiring NIV were included. No differences were found in median glottis angle during inspiration or peak inspiratory effort between PSV and NAVA at low and high support levels. CONCLUSIONS The present study showed that glottis patency during inspiration in patients with an acute exacerbation of COPD is not affected by mode (PSV or NAVA) or level of assist (5 or 15 cm H2O) during NIV.
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Affiliation(s)
- Eline Oppersma
- Cardiovascular and Respiratory Physiology, Faculty of Science and Technology, University of Twente, Postbox 217, 7500 AE, Enschede, The Netherlands; Biomedical Signals and Systems, Faculty of Electrical Engineering, Mathematics and Computer Science, University of Twente, Postbox 217, 7500 AE, Enschede, The Netherlands; Department of Intensive Care Medicine, Radboud University Medical Center, Postbox 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Jonne Doorduin
- Department of Intensive Care Medicine, Radboud University Medical Center, Postbox 9101, 6500 HB, Nijmegen, The Netherlands; Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Postbox 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Petra J Gooskens
- Cardiovascular and Respiratory Physiology, Faculty of Science and Technology, University of Twente, Postbox 217, 7500 AE, Enschede, The Netherlands; Department of Intensive Care Medicine, Radboud University Medical Center, Postbox 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Lisanne H Roesthuis
- Department of Intensive Care Medicine, Radboud University Medical Center, Postbox 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Erik H F M van der Heijden
- Department of Pulmonology, Radboud University Medical Center, Postbox 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Johannes G van der Hoeven
- Department of Intensive Care Medicine, Radboud University Medical Center, Postbox 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Peter H Veltink
- Biomedical Signals and Systems, Faculty of Electrical Engineering, Mathematics and Computer Science, University of Twente, Postbox 217, 7500 AE, Enschede, The Netherlands.
| | - Leo M A Heunks
- Department of Intensive Care Medicine, Radboud University Medical Center, Postbox 9101, 6500 HB, Nijmegen, The Netherlands; Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Postbox 7057, 1007MB, Amsterdam, The Netherlands.
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Aarrestad S, Qvarfort M, Kleiven AL, Tollefsen E, Skjønsberg OH, Janssens JP. Sleep related respiratory events during non-invasive ventilation of patients with chronic hypoventilation. Respir Med 2017; 132:210-216. [DOI: 10.1016/j.rmed.2017.10.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 10/12/2017] [Accepted: 10/31/2017] [Indexed: 12/14/2022]
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Vrijsen B, Buyse B, Belge C, Vanpee G, Van Damme P, Testelmans D. Randomized cross-over trial of ventilator modes during non-invasive ventilation titration in amyotrophic lateral sclerosis. Respirology 2017; 22:1212-1218. [DOI: 10.1111/resp.13046] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 01/31/2017] [Accepted: 02/02/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Bart Vrijsen
- Department of Pulmonology and Leuven University Centre for Sleep and Wake Disorders (LUCS); University Hospitals Leuven; Leuven Belgium
- Faculty of Kinesiology and Rehabilitation Sciences; KU Leuven; Leuven Belgium
| | - Bertien Buyse
- Department of Pulmonology and Leuven University Centre for Sleep and Wake Disorders (LUCS); University Hospitals Leuven; Leuven Belgium
- Department of Clinical and Experimental Medicine; KU Leuven; Leuven Belgium
| | - Catharina Belge
- Department of Pulmonology and Leuven University Centre for Sleep and Wake Disorders (LUCS); University Hospitals Leuven; Leuven Belgium
- Department of Clinical and Experimental Medicine; KU Leuven; Leuven Belgium
| | - Goele Vanpee
- Department of Pulmonology and Leuven University Centre for Sleep and Wake Disorders (LUCS); University Hospitals Leuven; Leuven Belgium
- Faculty of Kinesiology and Rehabilitation Sciences; KU Leuven; Leuven Belgium
| | - Philip Van Damme
- Department of Neurology; University Hospitals Leuven; Leuven Belgium
- Department of Neurosciences; KU Leuven - University of Leuven, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease (LIND); Leuven Belgium
| | - Dries Testelmans
- Department of Pulmonology and Leuven University Centre for Sleep and Wake Disorders (LUCS); University Hospitals Leuven; Leuven Belgium
- Department of Clinical and Experimental Medicine; KU Leuven; Leuven Belgium
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Sleep-Disordered Breathing in Neuromuscular Disease: Diagnostic and Therapeutic Challenges. Chest 2017; 152:880-892. [PMID: 28372949 DOI: 10.1016/j.chest.2017.03.023] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 02/23/2017] [Accepted: 03/21/2017] [Indexed: 12/11/2022] Open
Abstract
Normal sleep-related rapid eye movement sleep atonia, reduced lung volumes, reduced chemosensitivity, and impaired airway dilator activity become significant vulnerabilities in the setting of neuromuscular disease. In that context, the compounding effects of respiratory muscle weakness and disease-specific features that promote upper airway collapse or cause dilated cardiomyopathy contribute to various sleep-disordered breathing events. The reduction in lung volumes with neuromuscular disease is further compromised by sleep and the supine position, exaggerating the tendency for upper airway collapse and desaturation with sleep-disordered breathing events. The most commonly identified events are diaphragmatic/pseudo-central, due to a decrease in the rib cage contribution to the tidal volume during phasic rapid eye movement sleep. Obstructive and central sleep apneas are also common. Noninvasive ventilation can improve survival and quality of sleep but should be used with caution in the context of dilated cardiomyopathy or significant bulbar symptoms. Noninvasive ventilation can also trigger sleep-disordered breathing events, including ineffective triggering, autotriggering, central sleep apnea, and glottic closure, which compromise the potential benefits of the intervention by increasing arousals, reducing adherence, and impairing sleep architecture. Polysomnography plays an important diagnostic and therapeutic role by correctly categorizing sleep-disordered events, identifying sleep-disordered breathing triggered by noninvasive ventilation, and improving noninvasive ventilation settings. Optimal management may require dedicated hypoventilation protocols and a technical staff well versed in the identification and troubleshooting of respiratory events.
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Nasal intermittent positive pressure ventilation in preterm infants: Equipment, evidence, and synchronization. Semin Fetal Neonatal Med 2016; 21:146-53. [PMID: 26922562 DOI: 10.1016/j.siny.2016.01.003] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The use of nasal intermittent positive pressure ventilation (NIPPV) as respiratory support for preterm infants is well established. Evidence from randomized trials indicates that NIPPV is advantageous over continuous positive airway pressure (CPAP) as post-extubation support, albeit with varied outcomes between NIPPV techniques. Randomized data comparing NIPPV with CPAP as primary support, and for the treatment of apnea, are conflicting. Intrepretation of outcomes is limited by the multiple techniques and devices used to generate and deliver NIPPV. This review discusses the potential mechanisms of action of NIPPV in preterm infants, the evidence from clinical trials, and summarizes recommendations for practice.
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Neurally adjusted ventilatory assist (NAVA) allows patient-ventilator synchrony during pediatric noninvasive ventilation: a crossover physiological study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:44. [PMID: 25886793 PMCID: PMC4342194 DOI: 10.1186/s13054-015-0770-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 01/23/2015] [Indexed: 11/16/2022]
Abstract
Introduction The need for intubation after a noninvasive ventilation (NIV) failure is frequent in the pediatric intensive care unit (PICU). One reason is patient-ventilator asynchrony during NIV. Neurally adjusted ventilatory assist (NAVA) is a mode of ventilation controlled by the patient’s neural respiratory drive. The aim of this study was to assess the feasibility and tolerance of NIV-NAVA in children and to evaluate its impact on synchrony and respiratory effort. Methods This prospective, physiologic, crossover study included 13 patients requiring NIV in the PICU of Sainte-Justine’s Hospital from October 2011 to May 2013. Patients were successively ventilated in conventional NIV as prescribed by the physician in charge (30 minutes), in NIV-NAVA (60 minutes), and again in conventional NIV (30 minutes). Electrical activity of the diaphragm (EAdi) and airway pressure were simultaneously recorded to assess patient-ventilator synchrony. Results NIV-NAVA was feasible and well tolerated in all patients. One patient asked to stop the study because of anxiety related to the leak-free facial mask. Inspiratory trigger dys-synchrony and cycling-off dys-synchrony were significantly shorter in NIV-NAVA versus initial and final conventional NIV periods (both P <0.05). Wasted efforts were also decreased in NIV-NAVA (all values expressed as median and interquartile values) (0 (0 to 0) versus 12% (4 to 20) and 6% (2 to 22), respectively; P <0.01). As a whole, total time spent in asynchrony was reduced to 8% (6 to 10) in NIV-NAVA, versus 27% (19 to 56) and 32% (21 to 38) in conventional NIV before and after NIV-NAVA, respectively (P =0.05). Conclusion NIV-NAVA is feasible and well tolerated in PICU patients and allows improved patient-ventilator synchronization. Larger controlled studies are warranted to evaluate the clinical impact of these findings. Trial registration ClinicalTrials.gov NCT02163382. Registered 9 June 2014.
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Acute Neonatal Respiratory Failure. PEDIATRIC AND NEONATAL MECHANICAL VENTILATION 2015. [PMCID: PMC7193706 DOI: 10.1007/978-3-642-01219-8_47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Acute respiratory failure requiring assisted ventilation is one of the most common reasons for admission to the neonatal intensive care unit. Respiratory failure is the inability to maintain either normal delivery of oxygen to the tissues or normal removal of carbon dioxide from the tissues. It occurs when there is an imbalance between the respiratory workload and ventilatory strength and endurance. Definitions are somewhat arbitrary but suggested laboratory criteria for respiratory failure include two or more of the following: PaCO2 > 60 mmHg, PaO2 < 50 mmHg or O2 saturation <80 % with an FiO2 of 1.0 and pH < 7.25 (Wen et al. 2004).
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Gonzalez-Bermejo J, Perrin C, Janssens JP, Pépin JL, Mroue G, Leger P, Langevin B, Rouault S, Rabec C, Rodenstein D. Proposition pour une analyse systématique de la polygraphie et de la polysomnographie afin d’identifier les évènements anormaux survenant pendant la ventilation non invasive. Rev Mal Respir 2014; 31:312-22. [DOI: 10.1016/j.rmr.2013.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 05/22/2013] [Indexed: 10/26/2022]
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15
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Lee HS, Min SR. Comparison of Effectiveness of Nasal Continuous Positive Airway Pressure and Nasal Intermittent Positive Pressure Ventilation for the Initial Treatment of Preterm Respiratory Distress Syndrome: A Prospective Pilot Study. NEONATAL MEDICINE 2014. [DOI: 10.5385/nm.2014.21.3.158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Hyeon-Soo Lee
- Department of Pediatrics, Kangwon National University Hospital, Chuncheon, Korea
- Institute of Medical Sciences, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Se Ra Min
- Department of Pediatrics, Kangwon National University Hospital, Chuncheon, Korea
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Rabec C, Rodenstein D, Leger P, Rouault S, Perrin C, Gonzalez-Bermejo J. [Ventilator modes and settings during non-invasive ventilation: effects on respiratory events and implications for their identification. 2011]. Rev Mal Respir 2013; 30:818-31. [PMID: 24314706 DOI: 10.1016/j.rmr.2013.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 05/22/2013] [Indexed: 11/26/2022]
Abstract
Compared with invasive ventilation, non-invasive ventilation (NIV) has two unique characteristics: its non-hermetic nature and the fact that the ventilator-lung assembly cannot be considered as a single-compartment model because of the presence of variable resistance represented by the upper airways. When NIV is initiated, the ventilator settings are determined empirically based on clinical evaluation and blood gas variations. However, NIV is predominantly applied during sleep. Consequently, to assess overnight patient-machine "agreement" and efficacy of ventilation, more specific and sophisticated monitoring is needed. The effectiveness of NIV might therefore be more correctly assessed by sleep studies than by daytime assessment. The simplest monitoring can be done from flow and pressure curves from the mask or the ventilator circuit. Examination of these tracings can give useful information to evaluate if the settings chosen by the operator were the right ones for that patient. However, as NIV allows a large range of ventilatory parameters and settings, it is mandatory to have information about this to better understand patient-ventilator interaction. Ventilatory modality, mode of triggering, pressurization slope, use or not of positive end expiratory pressure and type of exhalation as well as ventilator performances may all have physiological consequences. Leaks and upper airway resistance variations may, in turn, modify these patterns. This article discusses the equipment available for NIV, analyses the effect of different ventilator modes and settings and of exhalation and connecting circuits on ventilatory traces and gives the background necessary to understand their impact on nocturnal monitoring of NIV.
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Affiliation(s)
- C Rabec
- Service de pneumologie et réanimation respiratoire, CHU de Dijon, 2, boulevard du Maréchal-de-Lattre-de-Tassigny, 21079 Dijon, France.
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Oppersma E, Doorduin J, van der Heijden EHFM, van der Hoeven JG, Heunks LMA. Noninvasive ventilation and the upper airway: should we pay more attention? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:245. [PMID: 24314000 PMCID: PMC4059377 DOI: 10.1186/cc13141] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In an effort to reduce the complications related to invasive ventilation, the use of noninvasive ventilation (NIV) has increased over the last years in patients with acute respiratory failure. However, failure rates for NIV remain high in specific patient categories. Several studies have identified factors that contribute to NIV failure, including low experience of the medical team and patient–ventilator asynchrony. An important difference between invasive ventilation and NIV is the role of the upper airway. During invasive ventilation the endotracheal tube bypasses the upper airway, but during NIV upper airway patency may play a role in the successful application of NIV. In response to positive pressure, upper airway patency may decrease and therefore impair minute ventilation. This paper aims to discuss the effect of positive pressure ventilation on upper airway patency and its possible clinical implications, and to stimulate research in this field.
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Janssens JP, Borel JC, Pépin JL. [Nocturnal monitoring of home non-invasive ventilation: Contribution of simple tools such as pulse-oximetry, capnography, built-in ventilator software and autonomic markers of sleep fragmentation]. Rev Mal Respir 2013; 31:107-18. [PMID: 24602678 DOI: 10.1016/j.rmr.2013.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 05/26/2013] [Indexed: 10/26/2022]
Abstract
Complex respiratory events, which may have a detrimental effect on both quality of sleep and control of nocturnal hypoventilation, occur during sleep in patients treated by non-invasive ventilation (NIV). Among these events are patient-ventilator asynchrony, increases in upper airway resistance with or without increased respiratory drive, and leaks. Detection of these events is important in order to select the most appropriate ventilator settings and interface. Simple tools can provide important information when monitoring NIV. Pulse-oximetry is important to ensure that an adequate SpO2 is provided, and to detect either prolonged or short and recurrent desaturations. However, the specificity of pulse-oximetry tracings under NIV is low. Transcutaneous capnography discriminates between hypoxemia related to V/Q mismatch and hypoventilation, documents correction of nocturnal hypoventilation, and may detect ventilator-induced hyperventilation, a possible cause for central apnea/hypopnea and glottic closure. Data provided by ventilator software helps the clinician by estimating ventilation, tidal volume, leaks, rate of inspiratory or expiratory triggering by the patient, although further validation of these signals by independent studies is indicated. Finally, autonomic markers of sympathetic tone using signals such as pulse wave amplitude of the pulse-oximetry signal can provide reliable information of sleep fragmentation.
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Affiliation(s)
- J-P Janssens
- Centre antituberculeux, division of pulmonary diseases, Geneva university hospital, rue Gabrielle Perret-Gentil 4, 1211 Geneva 14, Suisse.
| | - J-C Borel
- Laboratoire du sommeil, CHU de Grenoble, BP 217X, 38043 Grenoble cedex, France; Association médico-technique Agir à dom, 29-31, boulevard des Alpes, 38240 Meylan, France
| | - J-L Pépin
- Laboratoire du sommeil, CHU de Grenoble, BP 217X, 38043 Grenoble cedex, France
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Contal O, Adler D, Borel JC, Espa F, Perrig S, Rodenstein D, Pépin JL, Janssens JP. Impact of Different Backup Respiratory Rates on the Efficacy of Noninvasive Positive Pressure Ventilation in Obesity Hypoventilation Syndrome. Chest 2013; 143:37-46. [DOI: 10.1378/chest.11-2848] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Andrade FH. Noninvasive ventilation in neonates: the lungs don't like it! J Appl Physiol (1985) 2008; 105:1385-6. [PMID: 18772324 DOI: 10.1152/japplphysiol.91153.2008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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21
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Cuvelier A. Actualités dans l’insuffisance respiratoire chronique. Rev Mal Respir 2008. [DOI: 10.1016/s0761-8425(08)74072-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Roy B, Samson N, Moreau-Bussière F, Ouimet A, Dorion D, Mayer S, Praud JP. Mechanisms of active laryngeal closure during noninvasive intermittent positive pressure ventilation in nonsedated lambs. J Appl Physiol (1985) 2008; 105:1406-12. [PMID: 18703758 DOI: 10.1152/japplphysiol.90727.2008] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The present study stems from our recent demonstration (Moreau-Bussiere F, Samson N, St-Hilaire M, Reix P, Lafond JR, Nsegbe E, Praud JP. J Appl Physiol 102: 2149-2157, 2007) that a progressive increase in nasal intermittent positive pressure ventilation (nIPPV) leads to active glottal closure in nonsedated, newborn lambs. The aim of the study was to determine whether the mechanisms involved in this glottal narrowing during nIPPV originate from upper airway receptors and/or from bronchopulmonary receptors. Two groups of newborn lambs were chronically instrumented for polysomnographic recording: the first group of five lambs underwent a two-step bilateral thoracic vagotomy using video-assisted thoracoscopic surgery (bilateral vagotomy group), while the second group, composed of six lambs, underwent chronic laryngotracheal separation (isolated upper airway group). A few days later, polysomnographic recordings were performed to assess glottal muscle electromyography during step increases in nIPPV (volume control mode). Results show that active glottal narrowing does not develop when nIPPV is applied on the upper airways only, and that this narrowing is prevented by bilateral vagotomy when nIPPV is applied on intact airways. In conclusion, active glottal narrowing in response to increasing nIPPV originates from bronchopulmonary receptors.
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Affiliation(s)
- Bianca Roy
- Neonatal Respiratory Research Unit, Department of Pediatrics and Physiology, Université de Sherbrooke, Quebec, Canada J1H 5N4
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23
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Hutchison AA, Bignall S. Non-invasive positive pressure ventilation in the preterm neonate: reducing endotrauma and the incidence of bronchopulmonary dysplasia. Arch Dis Child Fetal Neonatal Ed 2008; 93:F64-8. [PMID: 17768159 DOI: 10.1136/adc.2006.103770] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- A A Hutchison
- Division of Neonatology, Department of Pediatrics, University of South Florida, Tampa, FL 33606, USA.
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24
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Guo YF, Sforza E, Janssens JP. Respiratory patterns during sleep in obesity-hypoventilation patients treated with nocturnal pressure support: a preliminary report. Chest 2007; 131:1090-9. [PMID: 17426214 DOI: 10.1378/chest.06-1705] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The obesity-hypoventilation syndrome (OHS), commonly defined as a combination of obesity and diurnal hypercapnia, is efficiently treated using nasal positive pressure ventilation (NPPV). The present study aimed to determine whether nocturnal polysomnography allows detection of respiratory disturbances occurring in patients with OHS treated with NPPV that may interfere with the quality of sleep and of ventilatory support, and are not detected by nocturnal pulse oximetry and capnography. METHODS Twenty OHS patients in stable clinical condition treated by NPPV for at least 3 months with a bilevel pressure support ventilator were studied. All patients underwent single-night polysomnography under NPPV including transcutaneous measurement of Pco(2) (TcPco(2)). Four types of respiratory events were defined and quantified: patient/ventilator desynchronization, periodic breathing (PB), autotriggering, and apnea-hypopneas. RESULTS Eleven patients (55%) exhibited desynchronization occurring mostly in slow-wave sleep and rapid eye movement sleep and associated with arousals but not inducing significant changes in TcPco(2) or oxygen saturation using pulse oximetry (Spo(2)). Eight patients (40%) showed a high index of PB, mostly occurring in light sleep and associated with more severe nocturnal hypoxemia. Autotriggering was sporadic and usually limited to one or two breaths, although prolonged and asymptomatic autotriggering occurred in one patient during 10.6% of total sleep time. CONCLUSIONS Patient/ventilatory asynchrony and PB are respiratory patterns occurring frequently in OHS patients treated using NPPV. Nocturnal monitoring of Spo(2) and TcPco(2), commonly used to assess the efficacy of ventilatory support, do not adequately explore this aspect of therapy that might influence its efficacy as well as sleep quality.
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Affiliation(s)
- Yan Fei Guo
- Centre antituberculeux, Service de Pneumologie, Hôpitaux Universitaires de Genève, 25 rue Micheli-du-Crest, 1211 Geneva 14, Switzerland
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25
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Guerin C, Richard JC. Measurement of respiratory system resistance during mechanical ventilation. Intensive Care Med 2007; 33:1046-9. [PMID: 17457568 DOI: 10.1007/s00134-007-0652-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2006] [Accepted: 04/02/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND The measurement of respiratory system resistance during mechanical ventilation is important to ascertain the causes of increase in airway pressure during volume-controlled ventilation, which may include airways resistance and decreased respiratory system compliance. DISCUSSION Separation of total resistance from compliance of the respiratory system can be assessed by the end-inspiratory hold maneuver that separates peak pressure from plateau pressure. CONCLUSIONS Although this method assumes a homogeneous respiratory system, it has proven useful clinically to separate flow-dependence issues such as bronchospasm or endotracheal tube obstruction from stiff lungs (acute lung injury) or decrease chest wall (abdominal distension) compliance.
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Affiliation(s)
- Claude Guerin
- Hôpital de la Croix Rousse and Université de Lyon, Service de Réanimation Médicale, 103 Grande Rue de la Croix Rousse, 69004 Lyon, France.
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Moreau-Bussière F, Samson N, St-Hilaire M, Reix P, Lafond JR, Nsegbe E, Praud JP. Laryngeal response to nasal ventilation in nonsedated newborn lambs. J Appl Physiol (1985) 2007; 102:2149-57. [PMID: 17332270 DOI: 10.1152/japplphysiol.00891.2006] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Although endoscopic studies in adult humans have suggested that laryngeal closure can limit alveolar ventilation during nasal intermittent positive pressure ventilation (nIPPV), there are no available data regarding glottal muscle activity during nIPPV. In addition, laryngeal behavior during nIPPV has not been investigated in neonates. The aim of the present study was to assess laryngeal muscle response to nIPPV in nonsedated newborn lambs. Nine newborn lambs were instrumented for recording states of alertness, electrical activity [electromyograph (EMG)] of glottal constrictor (thyroarytenoid, TA) and dilator (cricothyroid, CT) muscles, EMG of the diaphragm (Dia), and mask and tracheal pressures. nIPPV in pressure support (PS) and volume control (VC) modes was delivered to the lambs via a nasal mask. Results show that increasing nIPPV during wakefulness and quiet sleep led to a progressive disappearance of Dia and CT EMG and to the appearance and subsequent increase in TA EMG during inspiration, together with an increase in trans-upper airway pressure (TUAP). On rare occasions, transmission of nIPPV through the glottis was prevented by complete, active glottal closure, a phenomenon more frequent during active sleep epochs, when irregular bursts of TA EMG were observed. In conclusion, results of the present study suggest that active glottal closure develops with nIPPV in nonsedated lambs, especially in the VC mode. Our observations further suggest that such closure can limit lung ventilation when raising nIPPV in neonates.
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Affiliation(s)
- François Moreau-Bussière
- Neonatal Respiratory Research Unit, Department of Pediatrics, Université de Sherbrooke, J1H 5N4 Quebec, Canada
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Achour L, Letellier C, Cuvelier A, Vérin E, Muir JF. Asynchrony and cyclic variability in pressure support noninvasive ventilation. Comput Biol Med 2007; 37:1308-20. [PMID: 17258187 DOI: 10.1016/j.compbiomed.2006.12.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2005] [Revised: 12/06/2006] [Accepted: 12/06/2006] [Indexed: 10/23/2022]
Abstract
Noninvasive mechanical ventilation is an effective procedure to manage patients with acute or chronic respiratory failure. Most ventilators act as flow generators that assist spontaneous respiratory cycles by delivering inspiratory and expiratory pressures. This allows the patient to improve alveolar ventilation and subsequent pulmonary gas exchanges. The interaction between the patient and his ventilator are therefore crucial for tolerance and acceptability and part of this interaction is the facility to trigger the ventilator at the beginning of the inspiration. This is directly related to patients' discomfort which is not quantified today. Phase portraits reconstructed from the airflow and first-return maps built on the total breath duration were used to investigate the quality of the patient-ventilator interaction. Phase synchronization can be identified from phase portrait and the breath-to-breath variability is well characterized by return maps. This paper is a first step in the direction of automatically estimating the comfort from measurements and not from a necessarily subjective answer given by the patient. These tools could be helpful for the physicians to set the ventilator parameters.
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Affiliation(s)
- Linda Achour
- CORIA UMR 6614 - Université de Rouen, Av. de l'Université, BP 12, F-76801 Saint-Etienne du Rouvray cedex, France
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28
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Tuggey JM, Elliott MW. Titration of non-invasive positive pressure ventilation in chronic respiratory failure. Respir Med 2006; 100:1262-9. [PMID: 16310352 DOI: 10.1016/j.rmed.2005.10.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2005] [Revised: 10/12/2005] [Accepted: 10/13/2005] [Indexed: 11/22/2022]
Abstract
Non-invasive ventilation (NIV) is widely used for acute and chronic respiratory failure. If arterial blood gas tensions do not improve, the level of support can be increased. However, there may be a limit above which increasing ventilatory support leads only to greater interface leak with no improvement in ventilation. The aim of this study was to establish whether there is such a limit. During a daytime study in 24 ventilated stable patients (10 with chronic obstructive pulmonary disease (COPD), 14 with chest wall deformity, CWD), inspiratory pressures up to 20 cm H(2)O and set tidal volumes up to 10 ml kg(-1) were associated with mask leak of <5 l min(-1). Although leak increased with higher levels of support, there was still an increase in minute ventilation. The mean (2 sd) tolerated pressure was 24 cm H(2)O (8-40) in both groups, and set tidal volume 12.7 ml kg(-1) (5.0-20.4) in CWD and 9.6 ml kg(-1) (3.9-14.8) in COPD. Measures of respiratory effort were significantly reduced at all levels with both forms of ventilatory support. There is debate about whether the therapeutic aim of NIV should be to reduce respiratory muscle effort, or to reverse nocturnal hypoventilation. We conclude that if the primary aim is to improve arterial blood gas tensions and this is not achieved, higher levels of ventilation can be obtained using greater pressure or volume, despite additional interface leak. If the aim is to abolish muscle effort completely, there is little to be gained by increasing the level of inspiratory pressure above 20 (CWD) or 25 (COPD) cm H(2)O.
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Affiliation(s)
- Justin M Tuggey
- Department of Respiratory Medicine, St. James's University Hospital, Beckett Street, Leeds LS9 7TF, UK.
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29
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Rabec CA, Reybet-Degat O, Bonniaud P, Fanton A, Camus P. [Leak monitoring in noninvasive ventilation]. Arch Bronconeumol 2005; 40:508-17. [PMID: 15530343 DOI: 10.1016/s1579-2129(06)60366-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Nasal mask ventilation has been shown to be effective, but outcomes do not always match expectations because of mouth leaks, patient-ventilator asynchrony, or decreased upper airway patency. These developments are detected when they lead ultimately to circuit leaks that lower the effectiveness of ventilation through pressure loss, poor inspiratory triggering, and prolonged inspiratory time. The quality of sleep is affected, and adverse effects and treatment intolerance may arise. A number of ways to detect leaks and their practical consequences are proposed in this article. We applied 310 leak-detection procedures to 177 patients who had disappointing clinical, gasometric, or polysomnographic outcomes of ventilation. The leak-detection procedures varied according to the type of ventilation and the supposed underlying pathophysiological mechanism. Significant leaks were detected in 132 patients (76%); therapeutic changes were then prescribed to optimize outcomes. We present a practical method to apply in patients with suboptimal ventilation outcomes. If leaks can be detected during treatment, the probable cause of treatment failure can sometimes be established and possible pathophysiological mechanisms better understood. With this knowledge, it may be possible to improve ventilation.
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Affiliation(s)
- C A Rabec
- Service de Pneumologie et Réanimation Respiratoire, Centre Hospitalier et Universitaire de Dijon, Dijon, France.
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30
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Rodenstein DO. [The travels of a pulmonologist through the upper airway]. Arch Bronconeumol 2004; 40:178-82. [PMID: 15030732 DOI: 10.1016/s1579-2129(06)60210-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- D O Rodenstein
- Servicio de Neumología, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
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Jounieaux V, Rodenstein DO. Assistance ventilatoire à domicile : justifications et contraintes physiopathologiques. Rev Mal Respir 2004; 21:358-66. [PMID: 15211245 DOI: 10.1016/s0761-8425(04)71295-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Domiciliary assisted ventilation (DAV) may be undertaken invasively or non-invasively. Non-invasive DAV is used for patients suffering from alveolar hypoventilation due to restrictive pathology. Invasive DAV is reserved for "indications of necessity" that is when non-invasive ventilation is contraindicated due to the absence of adequate cough and for alveolar hypoventilation leading to hypercapnoea during spontaneous ventilation. STATE OF THE ART The main pathophysiological limitation to non-invasive ventilation is the interference of the glottis. In this mode the glottis imposes a variable resistance to the ventilation delivered. Its behaviour is more predictable during Volume controlled than during pressure controlled ventilation. The control parameters of a Volume controlled ventilator are very different from those used in invasive ventilation during which the respiratory system may be regarded as a single compartment (provided a cuffed tube bypasses the upper airway). In non-invasive DAV: mode VCM, tidal volume 13 mls kg(-1), rate 20 cycles min(-1), insp/exp ratio 1/1.2. In invasive DAV: mode VCM, tidal volume 8-10 mls kg(-1), rate 12 cycles min(-1), insp/exp ratio depending on the pathology 1/2. PERSPECTIVES As non-invasive DAV is essentially delivered during sleep the parameters for each patient can be optimised during polysomnography because waking, leading to a partial glottic occlusion, interferes with the ventilation delivered. CONCLUSIONS Recent understanding of the way the glottis interferes with mechanical ventilation when delivered non-invasively should lead to a revision of earlier practices based on invasive ventilation.
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Affiliation(s)
- V Jounieaux
- Service de Pneumologie et Unité de Réanimation Respiratoire, Centre Hospitalier Universitaire Sud, 80054 Amiens Cedex 1, France.
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Patroniti N, Verweij M, Kolobow T. Glottic-modulated lung ventilation during continuous transtracheal gas insufflation: an experimental study. Crit Care Med 2003; 31:1461-7. [PMID: 12771619 DOI: 10.1097/01.ccm.0000065780.29668.72] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We investigated a new method of pulmonary ventilation that included a minitracheostomy, a reverse thrust catheter to deliver continuous flow of gas to the carina, and a threshold valve to avoid lung overinflation. In six lightly sedated healthy sheep, at a continuous flow of 5, 10, or 15 L/min and a threshold valve of 5, 10, 15, or 20 cm H(2)O, we observed a novel respiratory pattern that was characterized either by active lung inflation followed by passive and prolonged inspiratory hold (mixed pattern) or by an absence of all active inspiratory effort and only passive inflation of the lungs (passive pattern). We correlated airway pressure changes with direct visualization of the glottic opening through a fiberoptic bronchoscope. We measured airway pressures at the level of the carina, the subglottic level, and in the pleural space, and respiratory events were monitored through inductive plethysmography. An increase in continuous flow, threshold valve, or both resulted in 1) an increase in glottic breathing; 2) a decrease in respiratory rate, with a decrease in inspiratory pleural pressure excursion; or 3) an increased inspiratory/expiratory ratio and mean airway pressure. During transtracheal gas insufflation, as in this study, a novel respiratory pattern evolved that was modulated by the glottis, accompanied by a decreased effort of breathing; coughing and swallowing remained, and vocalization remained unimpaired.
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Affiliation(s)
- Nicolo Patroniti
- Department of Surgical Science and Intensive Care, University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy.
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Glérant JC, Jounieaux V, Parreira VF, Dury M, Aubert G, Rodenstein DO. Effects of intermittent negative pressure ventilation on effective ventilation in normal awake subjects. Chest 2002; 122:99-107. [PMID: 12114344 DOI: 10.1378/chest.122.1.99] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
RATIONALE Previous studies have shown that an increase in inspiratory pressure during nasal intermittent positive pressure ventilation (IPPV) does not result in increased effective minute ventilation (E) due to glottic interference. STUDY OBJECTIVES To test the consequences of increases in negative pressure ventilation (NPV) on V(E). MATERIAL AND METHODS Eight healthy awake subjects underwent NPV delivered by an iron lung. First, NPV was started at a respirator frequency (f) of 15 cycles per minute with an inspiratory negative pressure (INP) of - 15 cm H(2)O (F15-P15). Then, f was increased to 20 cycles per minute and INP was kept at - 15 cm H(2)O. Next, f was kept at 20 cycles per minute and INP was reduced to - 30 cm H(2)O (F20-P30). Finally, f was decreased to 15 cycles per minute and INP was kept at - 30 cm H(2)O. At each step and for each breath, effective tidal volume (VT), V(E), and end-tidal carbon dioxide pressure were measured. In three subjects, the glottis width was assessed using fiberoptic bronchoscopy. RESULTS From spontaneous breathing to the first step of NPV (F15-P15), we observed an inhibition of the phasic inspiratory diaphragmatic electromyogram concomitant to a significant increase in V(E) (p < 0.0005). For the group as a whole, the increase in mechanical ventilation (from F15-P15 to F20-P30) resulted in significant increases in VT and V(E) leading to hypocapnia (p < 0.0005). Moreover, the glottis width did not decrease with the increase in mechanical ventilation. CONCLUSIONS We conclude that in normal awake subjects, NPV allowed a significant increase in V(E). These results differ from those previously obtained with nasal IPPV in which the glottic width interferes with the delivered mechanical ventilation.
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Jounieaux V, Parreira VF, Aubert G, Dury M, Delguste P, Rodenstein DO. Effects of hypocapnic hyperventilation on the response to hypoxia in normal subjects receiving intermittent positive-pressure ventilation. Chest 2002; 121:1141-8. [PMID: 11948044 DOI: 10.1378/chest.121.4.1141] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE To confirm the hypothesis that the ventilatory response to hypoxia (VRH) may be abolished by hypocapnia. METHODS We studied four healthy subjects during intermittent positive-pressure ventilation delivered through a nasal mask (nIPPV). Delivered minute ventilation (Ed) was progressively increased to lower end-tidal carbon dioxide pressure (PETCO(2)) below the apneic threshold. Then, at different hypocapnic levels, nitrogen was added to induce falls in oxygen saturation, a hypoxic run (N(2) run). For each N(2) run, the reappearance of a diaphragmatic muscle activity and/or an increase in effective minute ventilation (E) and/or deformations in mask-pressure tracings were considered as a VRH, whereas unchanged tracings signified absence of a VRH. For the N(2) runs eliciting a VRH, the threshold response to hypoxia (TRh) was defined as the transcutaneous oxygen saturation level that corresponds to the beginning of the ventilatory changes. RESULTS Thirty-seven N(2) runs were performed (7 N(2) runs during wakefulness and 30 N(2) runs during sleep). For severe hypocapnia (PETCO(2) of 27.1 +/- 5.2 mm Hg), no VRH was noted, whereas a VRH was observed for N(2) runs performed at significantly higher PETCO(2) levels (PETCO(2) of 34.0 +/- 2.1 mm Hg, p < 0.001). Deep oxygen desaturation (up to 64%) never elicited a VRH when the PETCO(2) level was < 29.3 mm Hg, which was considered the carbon dioxide inhibition threshold. For the 16 N(2) runs inducing a VRH, no correlations were found between PETCO(2) and TRh and between TRh and both Ed and E. CONCLUSION During nIPPV, VRH is highly dependent on the carbon dioxide level and can be definitely abolished for severe hypocapnia.
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Affiliation(s)
- Vincent Jounieaux
- Pneumology Unit, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
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Abstract
In this paper, we review the effects of nocturnal mechanical ventilation on sleep. Indeed, although non-invasive assisted ventilation during sleep has been applied extensively, the exact effects of this treatment on sleep quality have not been thoroughly studied. In patients with severe chronic obstructive pulmonary disease and severe restrictive ventilatory defects, the resulting respiratory failure is aggravated by the specific effects of sleep on respiration. Non-invasive mechanical ventilation can lead to improvements in both ventilation and sleep quality. However, this is not always the case. Moreover, sleep-related leaks may jeopardize the efficiency of the ventilatory assistance which in turn may result in a deterioration in sleep quality. Non-invasive mechanical ventilation, if applied during sleep, should require a monitoring procedure during sleep with the aim of obtaining the best possible effects both on ventilation and on sleep quality.
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Affiliation(s)
- Mónica M González
- Service de Pneumologie, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
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Affiliation(s)
- S Mehta
- Division of Pulmonary and Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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Schönhofer B, Köhler D. Effect of non-invasive mechanical ventilation on sleep and nocturnal ventilation in patients with chronic respiratory failure. Thorax 2000; 55:308-13. [PMID: 10722771 PMCID: PMC1745735 DOI: 10.1136/thorax.55.4.308] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Chronic respiratory failure (CRF) is associated with nocturnal hypoventilation. Due to the interaction of sleep and breathing, sleep quality is reduced during nocturnal hypoventilation. Non-invasive mechanical ventilation (NMV), usually performed overnight, relieves symptoms of hypoventilation and improves daytime blood gas tensions in patients with CRF. The time course of the long term effect of NMV on sleep and breathing during both spontaneous ventilation (withdrawing the intervention) and NMV was investigated in patients with CRF due to thoracic restriction. METHODS Fifteen consecutive patients (13 women) of mean (SD) age 57.9 (12.0) years with CRF due to thoracic restriction were included in the study. During the one year observation period four polysomnographic studies were performed: three during spontaneous breathing without NMV-before initiation of NMV (T0) and after withdrawing NMV for one night at six months (T6) and 12 months (T12-)-and the fourth during NMV after 12 months (T12+). Daytime blood gas tensions and lung function were also measured. RESULTS Spontaneous ventilation (in terms of mean oxygen saturation) progressively improved (from T0 to T12-) during both REM sleep (24.8%, 95% CI 12.9 to 36.9) and NREM sleep (21.5%, 95% CI 12.4 to 30.6). Sleep quality during spontaneous ventilation also improved in terms of increased total sleep time (26. 8%, 95% CI 11.6 to 42.0) and sleep efficiency (17.5%, 95% CI 5.4 to 29.6) and decreased awakenings (54.0%, 95% CI 70.3 to 37.7). Accordingly, REM and NREM sleep stages 3 and 4 significantly improved. However, the most significant improvements in both nocturnal ventilation and sleep quality were seen during NMV at 12 months. CONCLUSIONS After long term NMV both spontaneous ventilation during sleep and sleep quality in patients with CRF due to thoracic restriction showed evidence of progressive improvement compared with baseline after withdrawal of NMV for a single night at six and 12 months. However, the greatest improvements in nocturnal ventilation and sleep were achieved during NMV at 12 months.
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Affiliation(s)
- B Schönhofer
- Krankenhaus Kloster Grafschaft, Zentrum für Pneumologie, Beatmungs- und Schlafmedizin, 57392 Schmallenberg- Grafschaft, Germany.
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Parreira VF, Delguste P, Jounieaux V, Aubert G, Dury M, Rodenstein DO. Effectiveness of controlled and spontaneous modes in nasal two-level positive pressure ventilation in awake and asleep normal subjects. Chest 1997; 112:1267-77. [PMID: 9367467 DOI: 10.1378/chest.112.5.1267] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
STUDY OBJECTIVES The purpose of the present study was to compare in awake and asleep healthy subjects, under nasal intermittent positive pressure ventilation (nIPPV) with a two-level intermittent positive pressure device (two-level nIPPV), the efficacy of the controlled and spontaneous modes, and of different ventilator settings in increasing effective minute ventilation (VE). PARTICIPANTS Eight healthy subjects were studied. SETTING In the controlled mode, inspiratory positive airway pressure (IPAP) was kept at 15 cm H2O, expiratory positive airway pressure (EPAP) at 4 cm H2O, and the inspiratory/expiratory (I/E) time ratio at 1. The respirator frequencies were 17 and 25/min. In the spontaneous mode experiment, IPAP was started at 10 cm H2O and progressively increased to 15 and 20 cm H2O; EPAP was kept at 4 cm H2O. MEASUREMENTS AND RESULTS We measured breath by breath the effective tidal volume (VT with respiratory inductive plethysmography), actual respiratory frequency (f), and effective VE. Using the controlled mode, effective VE was significantly higher on nIPPV than during spontaneous unassisted breathing, except in stage 2 nonrapid eye movement sleep at 17/min of frequency; increases in f from 17 to 25/min led to a significant decrease in VT reaching the lungs, during wakefulness and sleep; effective VE was higher at 25 than at 17/min of frequency only during sleep; periodic breathing was scarce and apneas were never observed. Using the spontaneous mode, with respect to awake spontaneous unassisted breathing, two-level nIPPV at 10 and 15 cm H2O of IPAP did not result in any significant increase in effective VE either in wakefulness or in sleep; only IPAP levels of 20 cm H2O resulted in a significant increase in effective VE; during sleep, effective VE was significantly lower than during wakefulness; respiratory rhythm instability (ie, periodic breathing and central apneas) were exceedingly common, and in some subjects extremely frequent, leading to surprisingly large falls in arterial oxygen saturation. CONCLUSIONS It appears that two-level nIPPV should be used in the controlled mode rather than in the spontaneous mode, since it seems easier to increase effective VE with a lower IPAP at a high frequency than at a high pressure using the spontaneous mode. We suggest that the initial respirator settings in the controlled mode should be an f around 20/min, an I/E ratio of 1, 15 cm H2O of IPAP, and EPAP as low as possible.
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Affiliation(s)
- V F Parreira
- Pneumology Unit, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
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Claman DM, Piper A, Sanders MH, Stiller R, Votteri BA. Why Be Limited To Nocturnal Noninvasive IPPV? To the Editor. Chest 1997. [DOI: 10.1378/chest.111.5.1472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Fontanari P, Burnet H, Zattara-Hartmann MC, Jammes Y. Changes in airway resistance induced by nasal inhalation of cold dry, dry, or moist air in normal individuals. J Appl Physiol (1985) 1996; 81:1739-43. [PMID: 8904594 DOI: 10.1152/jappl.1996.81.4.1739] [Citation(s) in RCA: 128] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Nasopulmonary bronchomotor reflexes elicited by mechanical or irritant stimulation of the nose have been described in animals and asthmatic patients. However, few studies were devoted to the consequences of nasal breathing of cold and dry air or of only dry or only moist air on the bronchomotor control in normal individuals. The present study reported changes in interruption resistance (Rint) measured during eupneic breathing of moderately cold (-4 or -10 degrees C) and dry [0.3% relative humidity (RH)] air or of room air at 23 degrees C that is either dry (0.3% RH) or moist (97% RH). Nasal inhalation of cold (-4 degrees C) dry air or of only dry air significantly increased baseline Rint value (17 and 21%, respectively) throughout the 15-min test periods. The response to cold was significantly accentuated when the air temperature was lowered to -10 degrees C (42%). After nasal anesthesia or inhalation of a cholinergic antagonist, cold air did not induce a change in Rint. Nasal inhalation of moist room air had no effect. No Rint changes were measured during oral breathing of the three test agents. It is concluded that the activation of cold receptors or osmoreceptors in the nasal mucosa induces protective bronchoconstrictor responses in normal individuals.
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Affiliation(s)
- P Fontanari
- Laboratoire de Physiopathologie Respiratoire Intégrée et Cellulaire, Centre National de la Recherche Scientifique 1630, Institut Jean Roche, Faculté de Médecine, Université de la Méditerrannée, Marseille, France
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Affiliation(s)
- J M Shneerson
- Respiratory Support and Sleep Centre, Papworth Hospital, Cambridge, UK
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