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Farré R, Navajas D. Ventilation Mechanics. Semin Respir Crit Care Med 2023; 44:511-525. [PMID: 37467769 DOI: 10.1055/s-0043-1770340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
A fundamental task of the respiratory system is to operate as a mechanical gas pump ensuring that fresh air gets in close contact with the blood circulating through the lung capillaries to achieve O2 and CO2 exchange. To ventilate the lungs, the respiratory muscles provide the pressure required to overcome the viscoelastic mechanical load of the respiratory system. From a mechanical viewpoint, the most relevant respiratory system properties are the resistance of the airways (R aw), and the compliance of the lung tissue (C L) and chest wall (C CW). Both airflow and lung volume changes in spontaneous breathing and mechanical ventilation are determined by applying the fundamental mechanical laws to the relationships between the pressures inside the respiratory system (at the airway opening, alveolar, pleural, and muscular) and R aw, C L, and C CW. These relationships also are the basis of the different methods available to measure respiratory mechanics during spontaneous and artificial ventilation. Whereas a simple mechanical model (R aw, C L, and C CW) describes the basic understanding of ventilation mechanics, more complex concepts (nonlinearity, inhomogeneous ventilation, or viscoelasticity) should be employed to better describe and measure ventilation mechanics in patients.
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Affiliation(s)
- Ramon Farré
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
- CIBER de Enfermedades Respiratorias, Madrid, Spain
- Institut Investigacions Biomediques August Pi Sunyer, Barcelona, Spain
| | - Daniel Navajas
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
- CIBER de Enfermedades Respiratorias, Madrid, Spain
- Institut de Bioenginyeria de Catalunya (IBEC), The Barcelona Institute of Science and Technology, Barcelona, Spain
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Plante V, Poirier C, Guay H, Said C, Sauthier M, Al-Omar S, Harrington K, Emeriaud G. Elevated Diaphragmatic Tonic Activity in PICU Patients: Age-Specific Definitions, Prevalence, and Associations. Pediatr Crit Care Med 2023; 24:447-457. [PMID: 36883829 DOI: 10.1097/pcc.0000000000003193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
OBJECTIVES Tonic diaphragmatic activity (tonic Edi, i.e., sustained diaphragm activation throughout expiration) reflects diaphragmatic effort to defend end-expiratory lung volumes. Detection of such elevated tonic Edi may be useful in identifying patients who need increased positive end-expiratory pressure. We aimed to: 1) identify age-specific definitions for elevated tonic Edi in ventilated PICU patients and 2) describe the prevalence and factors associated with sustained episodes of high tonic Edi. DESIGN Retrospective study using a high-resolution database. SETTING Single-center tertiary PICU. PATIENTS Four hundred thirty-one children admitted between 2015 and 2020 with continuous Edi monitoring. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We characterized our definition of tonic Edi using data from the recovery phase of respiratory illness (i.e., final 3 hr of Edi monitoring, excluding patients with significant persistent disease or with diaphragm pathology). High tonic Edi was defined as population data exceeding the 97.5th percentile, which for infants younger than 1 year was greater than 3.2 μV and for older children as greater than 1.9 μV. These thresholds were then used to identify patients with episodes of sustained elevated tonic Edi in the first 48 hours of ventilation (acute phase). Overall, 62 of 200 (31%) of intubated patients and 138 of 222 (62%) of patients on noninvasive ventilation (NIV) had at least one episode of high tonic Edi. These episodes were independently associated with the diagnosis of bronchiolitis (intubated patients: adjusted odds [aOR], 2.79 [95% CI, 1.12-7.11]); NIV patients: aOR, 2.71 [1.24-6.0]). There was also an association with tachypnea and, in NIV patients, more severe hypoxemia. CONCLUSIONS Our proposed definition of elevated tonic Edi quantifies abnormal diaphragmatic activity during expiration. Such a definition may help clinicians to identify those patients using abnormal effort to defend end-expiratory lung volume. In our experience, high tonic Edi episodes are frequent, especially during NIV and in patients with bronchiolitis.
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Affiliation(s)
- Virginie Plante
- Division of Pediatric Intensive Care, Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, QC, Canada
| | - Clarice Poirier
- Division of Pediatric Intensive Care, Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, QC, Canada
| | - Hélène Guay
- Division of Pediatric Intensive Care, Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, QC, Canada
| | - Carla Said
- Division of Pediatric Intensive Care, Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, QC, Canada
- Department of Mathematics, Université Paris-Saclay, Paris, France
| | - Michael Sauthier
- Division of Pediatric Intensive Care, Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, QC, Canada
| | - Sally Al-Omar
- Division of Pediatric Intensive Care, Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, QC, Canada
| | - Karen Harrington
- Division of Pediatric Intensive Care, Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, QC, Canada
| | - Guillaume Emeriaud
- Division of Pediatric Intensive Care, Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, QC, Canada
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Yentes JM, Liu WY, Zhang K, Markvicka E, Rennard SI. Updated Perspectives on the Role of Biomechanics in COPD: Considerations for the Clinician. Int J Chron Obstruct Pulmon Dis 2022; 17:2653-2675. [PMID: 36274993 PMCID: PMC9585958 DOI: 10.2147/copd.s339195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 09/24/2022] [Indexed: 11/05/2022] Open
Abstract
Patients with chronic obstructive pulmonary disease (COPD) demonstrate extra-pulmonary functional decline such as an increased prevalence of falls. Biomechanics offers insight into functional decline by examining mechanics of abnormal movement patterns. This review discusses biomechanics of functional outcomes, muscle mechanics, and breathing mechanics in patients with COPD as well as future directions and clinical perspectives. Patients with COPD demonstrate changes in their postural sway during quiet standing compared to controls, and these deficits are exacerbated when sensory information (eg, eyes closed) is manipulated. If standing balance is disrupted with a perturbation, patients with COPD are slower to return to baseline and their muscle activity is differential from controls. When walking, patients with COPD appear to adopt a gait pattern that may increase stability (eg, shorter and wider steps, decreased gait speed) in addition to altered gait variability. Biomechanical muscle mechanics (ie, tension, extensibility, elasticity, and irritability) alterations with COPD are not well documented, with relatively few articles investigating these properties. On the other hand, dyssynchronous motion of the abdomen and rib cage while breathing is well documented in patients with COPD. Newer biomechanical technologies have allowed for estimation of regional, compartmental, lung volumes during activity such as exercise, as well as respiratory muscle activation during breathing. Future directions of biomechanical analyses in COPD are trending toward wearable sensors, big data, and cloud computing. Each of these offers unique opportunities as well as challenges. Advanced analytics of sensor data can offer insight into the health of a system by quantifying complexity or fluctuations in patterns of movement, as healthy systems demonstrate flexibility and are thus adaptable to changing conditions. Biomechanics may offer clinical utility in prediction of 30-day readmissions, identifying disease severity, and patient monitoring. Biomechanics is complementary to other assessments, capturing what patients do, as well as their capability.
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Affiliation(s)
- Jennifer M Yentes
- Department of Kinesiology & Sport Management, Texas A&M University, College Station, TX, USA
| | - Wai-Yan Liu
- Department of Orthopaedic Surgery & Trauma, Máxima MC, Eindhoven, the Netherlands
- Department of Orthopaedic Surgery & Trauma, Catharina Hospital, Eindhoven, the Netherlands
| | - Kuan Zhang
- Department of Electrical & Computer Engineering, University of Nebraska at Lincoln, Lincoln, NE, USA
| | - Eric Markvicka
- Department of Electrical & Computer Engineering, University of Nebraska at Lincoln, Lincoln, NE, USA
- Department of Mechanical & Materials Engineering, University of Nebraska at Lincoln, Lincoln, NE, USA
| | - Stephen I Rennard
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Nebraska Medical Center, Omaha, NE, USA
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Grashoff J, Petersen E, Becher T, Rostalski P. Automatic Estimation of Respiratory Effort using Esophageal Pressure. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2019; 2019:4646-4649. [PMID: 31946899 DOI: 10.1109/embc.2019.8856345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Esophageal pressure is currently seen as the gold standard to quantify the respiratory effort during assisted spontaneous ventilation. Yet, the assessment of waveforms at the bedside is often complicated due to heavy interference by cardiac artifacts and due to the unknown dependency on the lung volume. We propose an algorithm that automatically removes artifacts and gives an estimate for the respiratory effort of a patient. The estimator is based on fitting a respiratory system model to the Campbell diagram and, thus, also gives insight into important patient parameters like the chest wall elastance. The feasibility of our approach is demonstrated using clinical datasets of patients on pressure support ventilation. The algorithm facilitates the interpretation of ventilatory waveforms and may support the overall assessment of patients.
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Respiratory Muscle Effort during Weaning: Reply. Anesthesiology 2019; 130:857. [DOI: 10.1097/aln.0000000000002697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Respiratory Muscle Effort during Expiration in Successful and Failed Weaning from Mechanical Ventilation. Anesthesiology 2018; 129:490-501. [DOI: 10.1097/aln.0000000000002256] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
Respiratory muscle weakness in critically ill patients is associated with difficulty in weaning from mechanical ventilation. Previous studies have mainly focused on inspiratory muscle activity during weaning; expiratory muscle activity is less well understood. The current study describes expiratory muscle activity during weaning, including tonic diaphragm activity. The authors hypothesized that expiratory muscle effort is greater in patients who fail to wean compared to those who wean successfully.
Methods
Twenty adult patients receiving mechanical ventilation (more than 72 h) performed a spontaneous breathing trial. Tidal volume, transdiaphragmatic pressure, diaphragm electrical activity, and diaphragm neuromechanical efficiency were calculated on a breath-by-breath basis. Inspiratory (and expiratory) muscle efforts were calculated as the inspiratory esophageal (and expiratory gastric) pressure–time products, respectively.
Results
Nine patients failed weaning. The contribution of the expiratory muscles to total respiratory muscle effort increased in the “failure” group from 13 ± 9% at onset to 24 ± 10% at the end of the breathing trial (P = 0.047); there was no increase in the “success” group. Diaphragm electrical activity (expressed as the percentage of inspiratory peak) was low at end expiration (failure, 3 ± 2%; success, 4 ± 6%) and equal between groups during the entire expiratory phase (P = 0.407). Diaphragm neuromechanical efficiency was lower in the failure versus success groups (0.38 ± 0.16 vs. 0.71 ± 0.36 cm H2O/μV; P = 0.054).
Conclusions
Weaning failure (vs. success) is associated with increased effort of the expiratory muscles and impaired neuromechanical efficiency of the diaphragm but no difference in tonic activity of the diaphragm.
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Ceriana P, Vitacca M, Carlucci A, Paneroni M, Pisani L, Nava S. Changes of Respiratory Mechanics in COPD Patients from Stable State to Acute Exacerbations with Respiratory Failure. COPD 2016; 14:150-155. [PMID: 27997251 DOI: 10.1080/15412555.2016.1254173] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Symptoms, clinical course, functional and biological data during an exacerbation of chronic obstructive pulmonary disease (EXCOPD) have been investigated, but data on physiological changes of respiratory mechanics during a severe exacerbation with respiratory acidosis requiring noninvasive mechanical ventilation (NIMV) are scant. The aim of this study was to evaluate changes of respiratory mechanics in COPD patients comparing data observed during EXCOPD with those observed during stable state in the recovery phase. In 18 COPD patients having severe EXCOPD requiring NIMV for global respiratory failure, we measured respiratory mechanics during both EXCOPD (T0) and once the patients achieved a stable state (T1). The diaphragm and inspiratory muscles effort was significantly increased under relapse, as well as the pressure-time product of the diaphragm and the inspiratory muscle (PTPdi and PTPes). The resistive loads to breathe (i.e., PEEPi,dyn, compliance and inspiratory resistances) were also markedly increased, while the maximal pressures generated by the diaphragm and the inspiratory muscles, together with forced expired volumes were decreased. All these indices statistically improved but with a great intrasubject variability in stable condition. Moreover, tension-time index (TTdi) significantly improved from the EXCOPD state to the condition of clinical stability (0.156 ± 0.04 at T0 vs. 0.082 ± 0.02 at T1 p < 0.001). During an EXCOPD, the load/capacity of the respiratory pump is impaired, and although the patients exhibit a rapid shallow breathing pattern, this does not necessarily correlate with a TTdi ≥ 0.15. These changes are reverted once they recover from the EXCOPD, despite a large variability between patients.
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Affiliation(s)
- Piero Ceriana
- a Respiratory Rehabilitation Division, Salvatore Maugeri Foundation IRCCS, Institute of Pavia , Pavia , Italy
| | - Michele Vitacca
- b Respiratory Rehabilitation Division, Salvatore Maugeri Foundation IRCCS, Institute of Lumezzane , Lumezzane , Italy
| | - Annalisa Carlucci
- a Respiratory Rehabilitation Division, Salvatore Maugeri Foundation IRCCS, Institute of Pavia , Pavia , Italy
| | - Mara Paneroni
- b Respiratory Rehabilitation Division, Salvatore Maugeri Foundation IRCCS, Institute of Lumezzane , Lumezzane , Italy
| | - Lara Pisani
- c Institute of Respiratory Diseases, Policlinico S. Orsola and Alma Mater University , Bologna , Italy
| | - Stefano Nava
- c Institute of Respiratory Diseases, Policlinico S. Orsola and Alma Mater University , Bologna , Italy
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Magder S, Serri K, Verscheure S, Chauvin R, Goldberg P. Active Expiration and the Measurement of Central Venous Pressure. J Intensive Care Med 2016; 33:430-435. [PMID: 27872408 DOI: 10.1177/0885066616678578] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To obtain a point prevalence estimate of alterations in central venous pressure (CVP) produced by active expiration in a consecutive series of intensive care patients. METHODS We evaluated CVP tracings taken by the nurses at their morning shift change in a consecutive series of 60 cardiac surgery and 59 noncardiac surgery patients. We also assessed change in values due to the change in transducer level. Three physicians and a nurse instructor independently reviewed the tracings and determined whether there was evidence of forced expiration and whether it was type A, defined by decreasing CVP during expiration, or type B, defined by increasing CVP during expiration. RESULTS Agreement for CVP value was 96% between a physician and a bedside nurse. Twenty-nine percent of participants had active expiration, evenly distributed between A and B types. Active expiration was not related to the type of surgery, use of bronchodilators, and the presence of chronic obstructive lung disease or abdominal distention. Active expiration was more common in nonventilated patients and patients not receiving vasopressor drugs, suggesting they were more awake. CONCLUSION Active expiration is common in critically ill patients. Failure to recognize it can result in important errors in the estimation of CVP and other hemodynamic measurements.
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Affiliation(s)
- Sheldon Magder
- 1 Division of Critical Care, Royal Victoria Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Karim Serri
- 2 Critical Care Department, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Québec
| | - Sara Verscheure
- 1 Division of Critical Care, Royal Victoria Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Renée Chauvin
- 1 Division of Critical Care, Royal Victoria Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Peter Goldberg
- 1 Division of Critical Care, Royal Victoria Hospital, McGill University Health Centre, Montreal, Quebec, Canada
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Liu L, Liu S, Xie J, Yang Y, Slutsky AS, Beck J, Sinderby C, Qiu H. Assessment of patient-ventilator breath contribution during neurally adjusted ventilatory assist in patients with acute respiratory failure. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:43. [PMID: 25882607 PMCID: PMC4339109 DOI: 10.1186/s13054-015-0775-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 01/07/2015] [Indexed: 12/18/2022]
Abstract
INTRODUCTION We previously showed in animals that the ratio of inspired tidal volume (Vtinsp) to inspiratory peak electrical activity of the diaphragm (EAdipk) can be used to quantify the respective patient and ventilator breath contributions (PVBCs) during neurally adjusted ventilatory assist (NAVA). The PVBC index has not been tested clinically. METHODS We studied 12 intubated and mechanically ventilated patients with acute respiratory failure and measured EAdipk, airway (Paw) and inspiratory esophageal pressure (Pes) and Vtinsp. We applied 11 different NAVA levels, increasing them every 3 minutes in steps of 0.3 cm H₂O/μV from 0 to 3.0 cmH₂O/μV. At each NAVA level, one breath was non-assisted (NAVA level 0). PVBC indices were calculated by relating Vtinsp/EAdipk of the non-assisted breath to Vtinsp/EAdipk of the assisted breath(s) using one ((N1)PVBC) or the mean value of five preceding assisted breaths ((X5)PVBC). During assisted breaths, inspiratory changes in Pes (∆Pes) and transpulmonary (ΔPtp) pressures were used to calculate the relative contribution of patient to total inspiratory lung-distending pressures (ΔPes/ΔPtp). Matching of respiratory drive indices and squaring of the PVBC was evaluated for their effect on the correlation between PVBC and ΔPes/ΔPtp. Linear regression analysis and Bland-Altman analysis were applied to compare indices. RESULTS Using an average of five assisted breaths prior to the non-assisted breath and squaring the PVBC ((X5)PVBC(2)) improved determination coefficients (P <0.05), adjusted the regression slope and intercept between PVBC and ΔPes/ΔPtp toward identity (P <0.05) and reduced bias (P <0.05). Matching EAdipk between non-assisted and assisted breaths within the range of 0.77 to 1.30 improved the relationship between (X5)PVBC(2) and ΔPes/ΔPtp (P <0.05) and abolished the need for EAdi normalization in the PVBC calculation (R(2) = 0.96; bias = 0.16 ± 0.06; precision = 0.33 ± 0.08 (mean and 95% confidence interval)). CONCLUSIONS This clinical study confirms previous experimental results showing that the PVBC(2) predicts the contribution of the inspiratory muscles versus that of the ventilator during NAVA, when differences in effort (EAdi) between non-assisted and assisted breaths are limited. PVBC could help to quantify and standardize the adjustment of the level of assist, and hence reduce the risks of excessive ventilatory assist in patients. TRIAL REGISTRATION ClinicalTrials.gov NCT01663480. Registered 9 August 2012.
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Affiliation(s)
- Ling Liu
- Department of Critical Care Medicine, Zhongda Hospital, Southeast University, School of Medicine, 87 Dingjiaqiao Street, Nanjing, 210009, China.
| | - Songqiao Liu
- Department of Critical Care Medicine, Zhongda Hospital, Southeast University, School of Medicine, 87 Dingjiaqiao Street, Nanjing, 210009, China.
| | - Jianfeng Xie
- Department of Critical Care Medicine, Zhongda Hospital, Southeast University, School of Medicine, 87 Dingjiaqiao Street, Nanjing, 210009, China.
| | - Yi Yang
- Department of Critical Care Medicine, Zhongda Hospital, Southeast University, School of Medicine, 87 Dingjiaqiao Street, Nanjing, 210009, China.
| | - Arthur S Slutsky
- Keenan Research Centre for Biomedical Science and Department of Critical Care, St Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada. .,Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Suit RFE3-805, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.
| | - Jennifer Beck
- Keenan Research Centre for Biomedical Science and Department of Critical Care, St Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada. .,Department of Pediatrics, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
| | - Christer Sinderby
- Keenan Research Centre for Biomedical Science and Department of Critical Care, St Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada. .,Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Suit RFE3-805, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.
| | - Haibo Qiu
- Department of Critical Care Medicine, Zhongda Hospital, Southeast University, School of Medicine, 87 Dingjiaqiao Street, Nanjing, 210009, China.
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Ciavaglia CE, Guenette JA, Langer D, Webb KA, Alberto Neder J, O'Donnell DE. Differences in respiratory muscle activity during cycling and walking do not influence dyspnea perception in obese patients with COPD. J Appl Physiol (1985) 2014; 117:1292-301. [DOI: 10.1152/japplphysiol.00502.2014] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
In patients with combined obesity and chronic obstructive pulmonary disease (COPD), dyspnea intensity at matched work rates during weight-supported cycling and weight-bearing walking is similar, despite consistent metabolic differences between test modalities. The present study examined the influence of differences in activity of the diaphragm and abdominal muscles during cycling and walking on intensity and quality of dyspnea at matched ventilation in obese patients with COPD. We compared respiratory muscle activity patterns and dyspnea ratings during incremental cycle and treadmill exercise tests, where work rate was matched, in 12 obese (body mass index 36.6 ± 5.4 kg/m2; mean ± SD) patients with moderate COPD. We used a multipair electrode-balloon catheter to compare electromyography of the diaphragm and esophageal, gastric, and transdiaphragmatic pressures during the two exercise tests. Ventilation, breathing pattern, operating lung volumes, global respiratory effort, and electrical activation of the diaphragm were similar across exercise modalities for a given work rate. The cycling position was associated with greater neuromuscular efficiency of the diaphragm ( P < 0.01), greater diaphragm use ( P < 0.01) measured by the ventilatory muscle recruitment index, and less expiratory muscle activity compared ( P < 0.01) with treadmill walking. However, intensity and quality of dyspnea were similar between exercise modalities. In obese patients with COPD, altered respiratory muscle activity due to body position differences between cycling and walking did not modulate perceived dyspnea when indirect measures of respiratory neural drive were unchanged.
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Affiliation(s)
- Casey E. Ciavaglia
- Respiratory Investigation Unit, Department of Medicine, Queen's University & Kingston General Hospital, Kingston, Ontario, Canada
| | - Jordan A. Guenette
- Respiratory Investigation Unit, Department of Medicine, Queen's University & Kingston General Hospital, Kingston, Ontario, Canada
- Department of Physical Therapy and UBC Centre for Heart Lung Innovation, University of British Columbia, Vancouver, British Columbia, Canada; and
| | - Daniel Langer
- Respiratory Investigation Unit, Department of Medicine, Queen's University & Kingston General Hospital, Kingston, Ontario, Canada
- Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - Katherine A. Webb
- Respiratory Investigation Unit, Department of Medicine, Queen's University & Kingston General Hospital, Kingston, Ontario, Canada
| | - J. Alberto Neder
- Respiratory Investigation Unit, Department of Medicine, Queen's University & Kingston General Hospital, Kingston, Ontario, Canada
| | - Denis E. O'Donnell
- Respiratory Investigation Unit, Department of Medicine, Queen's University & Kingston General Hospital, Kingston, Ontario, Canada
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Does expiratory muscle activity influence dynamic hyperinflation and exertional dyspnea in COPD? Respir Physiol Neurobiol 2014; 199:24-33. [DOI: 10.1016/j.resp.2014.04.005] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Revised: 04/15/2014] [Accepted: 04/18/2014] [Indexed: 11/24/2022]
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Hess A, Yu L, Klein I, De Mazancourt M, Jebrak G, Mal H, Brugière O, Fournier M, Courbage M, Dauriat G, Schouman-Clayes E, Clerici C, Mangin L. Neural mechanisms underlying breathing complexity. PLoS One 2013; 8:e75740. [PMID: 24098396 PMCID: PMC3789752 DOI: 10.1371/journal.pone.0075740] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 08/20/2013] [Indexed: 01/22/2023] Open
Abstract
Breathing is maintained and controlled by a network of automatic neurons in the brainstem that generate respiratory rhythm and receive regulatory inputs. Breathing complexity therefore arises from respiratory central pattern generators modulated by peripheral and supra-spinal inputs. Very little is known on the brainstem neural substrates underlying breathing complexity in humans. We used both experimental and theoretical approaches to decipher these mechanisms in healthy humans and patients with chronic obstructive pulmonary disease (COPD). COPD is the most frequent chronic lung disease in the general population mainly due to tobacco smoke. In patients, airflow obstruction associated with hyperinflation and respiratory muscles weakness are key factors contributing to load-capacity imbalance and hence increased respiratory drive. Unexpectedly, we found that the patients breathed with a higher level of complexity during inspiration and expiration than controls. Using functional magnetic resonance imaging (fMRI), we scanned the brain of the participants to analyze the activity of two small regions involved in respiratory rhythmogenesis, the rostral ventro-lateral (VL) medulla (pre-Bötzinger complex) and the caudal VL pons (parafacial group). fMRI revealed in controls higher activity of the VL medulla suggesting active inspiration, while in patients higher activity of the VL pons suggesting active expiration. COPD patients reactivate the parafacial to sustain ventilation. These findings may be involved in the onset of respiratory failure when the neural network becomes overwhelmed by respiratory overload We show that central neural activity correlates with airflow complexity in healthy subjects and COPD patients, at rest and during inspiratory loading. We finally used a theoretical approach of respiratory rhythmogenesis that reproduces the kernel activity of neurons involved in the automatic breathing. The model reveals how a chaotic activity in neurons can contribute to chaos in airflow and reproduces key experimental fMRI findings.
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Affiliation(s)
- Agathe Hess
- Laboratoire Matière et Systèmes complexes, UMR 7057, CNRS, Université Paris 7, Paris, France
- Service de Radiologie, APHP, Hôpital Bichat-Claude Bernard, Paris, France
| | - Lianchun Yu
- Laboratoire Matière et Systèmes complexes, UMR 7057, CNRS, Université Paris 7, Paris, France
- Institute of Theoretical Physics, Lanzhou University, Lanzhou, China
| | - Isabelle Klein
- Service de Radiologie, APHP, Hôpital Bichat-Claude Bernard, Paris, France
- Unité Inserm 698, Université Paris 7, Paris, France
| | - Marine De Mazancourt
- Laboratoire Matière et Systèmes complexes, UMR 7057, CNRS, Université Paris 7, Paris, France
- Ecole Normale Supérieure, Paris, France
| | - Gilles Jebrak
- Service de Pneumologie B, APHP, Hôpital Bichat-Claude Bernard, Paris, France
| | - Hervé Mal
- Service de Pneumologie B, APHP, Hôpital Bichat-Claude Bernard, Paris, France
| | - Olivier Brugière
- Service de Pneumologie B, APHP, Hôpital Bichat-Claude Bernard, Paris, France
| | - Michel Fournier
- Service de Pneumologie B, APHP, Hôpital Bichat-Claude Bernard, Paris, France
| | - Maurice Courbage
- Laboratoire Matière et Systèmes complexes, UMR 7057, CNRS, Université Paris 7, Paris, France
| | - Gaelle Dauriat
- Service de Pneumologie B, APHP, Hôpital Bichat-Claude Bernard, Paris, France
| | | | - Christine Clerici
- Département de Physiologie-Explorations fonctionnelles, APHP, Hôpital Bichat-Claude Bernard, Paris, France
- Unité Inserm 700, Université Paris 7, Paris, France
| | - Laurence Mangin
- Laboratoire Matière et Systèmes complexes, UMR 7057, CNRS, Université Paris 7, Paris, France
- Département de Physiologie-Explorations fonctionnelles, APHP, Hôpital Bichat-Claude Bernard, Paris, France
- Centre d’Investigation Clinique APHP, Hôpital Bichat, Paris, France
- * E-mail:
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Ora J, Laveneziana P, Wadell K, Preston M, Webb KA, O'Donnell DE. Effect of obesity on respiratory mechanics during rest and exercise in COPD. J Appl Physiol (1985) 2011; 111:10-9. [PMID: 21350021 DOI: 10.1152/japplphysiol.01131.2010] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The presence of obesity in COPD appears not to be a disadvantage with respect to dyspnea and weight-supported cycle exercise performance. We hypothesized that one explanation for this might be that the volume-reducing effects of obesity convey mechanical and respiratory muscle function advantages. Twelve obese chronic obstructive pulmonary disease (COPD) (OB) [forced expiratory volume in 1 s (FEV(1)) = 60%predicted; body mass index (BMI) = 32 ± 1 kg/m(2); mean ± SD] and 12 age-matched, normal-weight COPD (NW) (FEV(1) = 59%predicted; BMI = 23 ± 2 kg/m(2)) subjects were compared at rest and during symptom-limited constant-work-rate exercise at 75% of their maximum. Measurements included pulmonary function tests, operating lung volumes, esophageal pressure, and gastric pressure. OB vs. NW had a reduced total lung capacity (109 vs. 124%predicted; P < 0.05) and resting end-expiratory lung volume (130 vs. 158%predicted; P < 0.05). At rest, there was no difference in respiratory muscle strength but OB had greater (P < 0.05) static recoil and intra-abdominal pressures than NW. Peak ventilation, oxygen consumption, and exercise endurance times were similar in OB and NW. Pulmonary resistance fell (P < 0.05) at the onset of exercise in OB but not in NW. Resting inspiratory capacity, dyspnea/ventilation plots, and the ratio of respiratory muscle effort to tidal volume displacement were similar, as was the dynamic performance of the respiratory muscles including the diaphragm. In conclusion, the lack of increase in dyspnea and exercise intolerance in OB vs. NW could not be attributed to improvement in respiratory muscle function. Potential contributory factors included alterations in the elastic properties of the lungs, raised intra-abdominal pressures, reduced lung hyperinflation, and preserved inspiratory capacity.
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Affiliation(s)
- Josuel Ora
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston General Hospital, Kingston, Ontario, Canada
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Perez Bogerd S, Selleron B, Hotton R, Ferrali O, Sergysels R. Les techniques de médecine physique peuvent-elles pallier la distension ? Rev Mal Respir 2009; 26:1107-17. [DOI: 10.1016/s0761-8425(09)73537-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Sinderby C, Beck J. Proportional Assist Ventilation and Neurally Adjusted Ventilatory Assist—Better Approaches to Patient Ventilator Synchrony? Clin Chest Med 2008; 29:329-42, vii. [DOI: 10.1016/j.ccm.2008.01.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Kaneko H, Maruyama H, Sato H. Relationship between Expiratory Activity of the Lateral Abdominal Muscle and Exercise Tolerance in Chronic Obstructive Pulmonary Disease. J Phys Ther Sci 2008. [DOI: 10.1589/jpts.20.147] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Hideo Kaneko
- Department of Physical Therapy, School of Fukuoka Rehabilitation Sciences, International University of Health and Welfare
| | - Hitoshi Maruyama
- Department of Physical Therapy, School of Health Sciences, International University of Health and Welfare
| | - Hironori Sato
- Graduate School of Comprehensive Human Sciences, University of Tsukuba
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Parthasarathy S, Jubran A, Laghi F, Tobin MJ. Sternomastoid, rib cage, and expiratory muscle activity during weaning failure. J Appl Physiol (1985) 2007; 103:140-7. [PMID: 17395760 DOI: 10.1152/japplphysiol.00904.2006] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We hypothesized that patients who fail weaning from mechanical ventilation recruit their inspiratory rib cage muscles sooner than they recruit their expiratory muscles, and that rib cage muscle recruitment is accompanied by recruitment of sternomastoid muscles. Accordingly, we measured sternomastoid electrical activity and changes in esophageal (ΔPes) and gastric pressure (ΔPga) in 11 weaning-failure and 8 weaning-success patients. At the start of trial, failure patients exhibited a higher ΔPga-to-ΔPes ratio than did success patients ( P = 0.05), whereas expiratory rise in Pga was equivalent in the two groups. Between the start and end of the trial, failure patients developed additional increases in ΔPga-to-ΔPes ratio ( P < 0.0014) and the expiratory rise in Pga also increased ( P < 0.004). At the start of trial, sternomastoid activity was present in 8 of 11 failure patients contrasted with 1 of 8 success patients. Over the course of the trial, sternomastoid activity increased by 53.0 ± 9.3% in the failure patients ( P = 0.0005), whereas it did not change in the success patients. Failure patients recruited their respiratory muscles in a sequential manner. The sequence began with activity of diaphragm and greater-than-normal activity of inspiratory rib cage muscles; recruitment of sternomastoids and rib cage muscles approached near maximum within 4 min of trial commencement; expiratory muscles were recruited slowest of all. In conclusion, not only is activity of the inspiratory rib cage muscles increased during a failed weaning trial, but respiratory centers also recruit sternomastoid and expiratory muscles. Extradiaphragmatic muscle recruitment may be a mechanism for offsetting the effects of increased load on a weak diaphragm.
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Affiliation(s)
- Sairam Parthasarathy
- Division of Pulmonary and Critical Care Medicine, Edward Hines Jr. Veterans Administration Hospital, and Loyola University of Chicago Stritch School of Medicine, Hines, Illinois, USA
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Aliverti A, Carlesso E, Dellacà R, Pelosi P, Chiumello D, Pedotti A, Gattinoni L. Chest wall mechanics during pressure support ventilation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2006; 10:R54. [PMID: 16584534 PMCID: PMC1550890 DOI: 10.1186/cc4867] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2005] [Revised: 02/21/2006] [Accepted: 02/24/2006] [Indexed: 11/21/2022]
Abstract
Introduction During pressure support ventilation (PSV) a part of the breathing pattern is controlled by the patient, and synchronization of respiratory muscle action and the resulting chest wall kinematics is a valid indicator of the patient's adaptation to the ventilator. The aim of the present study was to analyze the effects of different PSV settings on ventilatory pattern, total and compartmental chest wall kinematics and dynamics, muscle pressures and work of breathing in patients with acute lung injury. Method In nine patients four different levels of PSV (5, 10, 15 and 25 cmH2O) were randomly applied with the same level of positive end-expiratory pressure (10 cmH2O). Flow, airway opening, and oesophageal and gastric pressures were measured, and volume variations for the entire chest wall, the ribcage and abdominal compartments were recorded by opto-electronic plethysmography. The pressure and the work generated by the diaphragm, rib cage and abdominal muscles were determined using dynamic pressure-volume loops in the various phases of each respiratory cycle: pre-triggering, post-triggering with the patient's effort combining with the action of the ventilator, pressurization and expiration. The complete breathing pattern was measured and correlated with chest wall kinematics and dynamics. Results At the various levels of pressure support applied, minute ventilation was constant, with large variations in breathing frequency/ tidal volume ratio. At pressure support levels below 15 cmH2O the following increased: the pressure developed by the inspiratory muscles, the contribution of the rib cage compartment to the total tidal volume, the phase shift between rib cage and abdominal compartments, the post-inspiratory action of the inspiratory rib cage muscles, and the expiratory muscle activity. Conclusion During PSV, the ventilatory pattern is very different at different levels of pressure support; in patients with acute lung injury pressure support greater than 10 cmH2O permits homogeneous recruitment of respiratory muscles, with resulting synchronous thoraco-abdominal expansion.
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Affiliation(s)
- Andrea Aliverti
- Dipartimento di Bioingegneria, Politecnico di Milano, Milano, Italy
| | | | - Raffaele Dellacà
- Dipartimento di Bioingegneria, Politecnico di Milano, Milano, Italy
| | - Paolo Pelosi
- Dipartimento Ambiente, Salute e Sicurezza, Universita' degli Studi dell'Insubria, Varese, Italy
| | - Davide Chiumello
- Istituto di Anestesia e Rianimazione, Fondazione IRCCS, Ospedale Maggiore Policlinico Mangiagalli Regina Elena, Milano, Italy
| | - Antonio Pedotti
- Dipartimento di Bioingegneria, Politecnico di Milano, Milano, Italy
| | - Luciano Gattinoni
- Università degli Studi, Milano, Italy
- Istituto di Anestesia e Rianimazione, Fondazione IRCCS, Ospedale Maggiore Policlinico Mangiagalli Regina Elena, Milano, Italy
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Abstract
The act of breathing depends on coordinated activity of the respiratory muscles to generate subatmospheric pressure. This action is compromised by disease states affecting anatomical sites ranging from the cerebral cortex to the alveolar sac. Weakness of the respiratory muscles can dominate the clinical manifestations in the later stages of several primary neurologic and neuromuscular disorders in a manner unique to each disease state. Structural abnormalities of the thoracic cage, such as scoliosis or flail chest, interfere with the action of the respiratory muscles-again in a manner unique to each disease state. The hyperinflation that accompanies diseases of the airways interferes with the ability of the respiratory muscles to generate subatmospheric pressure and it increases the load on the respiratory muscles. Impaired respiratory muscle function is the most severe consequence of several newly described syndromes affecting critically ill patients. Research on the respiratory muscles embraces techniques of molecular biology, integrative physiology, and controlled clinical trials. A detailed understanding of disease states affecting the respiratory muscles is necessary for every physician who practices pulmonary medicine or critical care medicine.
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Affiliation(s)
- Franco Laghi
- Division of Pulmonary and Critical Care Medicine, Edward Hines, Jr. VA Hospital, 111 N. 5th Avenue and Roosevelt Road, Hines, IL 60141, USA.
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