The study of maximal nasal inspiratory flow in humans

A Remote-Controlled Airbag Device Can Improve Upper Airway Collapsibility by Producing Head Elevation With Jaw Closure in Normal Subjects Under Propofol Anesthesia

Continuous maintenance of an appropriate position of the mandible and head purely by manual manipulation is difficult, although the maneuver can restore airway patency during sleep and anesthesia. The aim of this paper was to examine the effect of head elevation with jaw closure using a remote-controlled airbag device, such as the airbag system, on passive upper airway collapsibility during propofol anesthesia. Seven male subjects were studied. Propofol infusion was used for anesthesia induction and maintenance, with a target blood propofol concentration of 1.5–2 \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}\(\mu \) \end{document}g/ml. Nasal mask pressure (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}\({P}_{\text {N}}\) \end{document}) was intermittently reduced to evaluate upper airway collapsibility (passive \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}\({P}_{_{\text {CRIT}}}\) \end{document}) and upstream resistance (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}\({R}_{_{\text {US}}}\) \end{document}) at three different head and jaw positions, jaw opening position in the supine position, jaw opening position in the sniffing position with 6-cm head elevation, and jaw closure at a 6-cm height sniffing position. The 6-cm height sniffing position with jaw closure was achieved by an airbag device that was attached to the subject’s head-like headgear. Patient demographics, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}\({P}_{_{\text {CRIT}}}\) \end{document} and \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}\({R}_{_{\text {US}}}\) \end{document} in each condition were compared using one-way ANOVA with a post hoc Tukey test. \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}\({\rm P}<0.05\) \end{document} was considered significant. We also confirmed the effects of our airbag device on improvement of upper airway collapsibility in three obstructive sleep apnea patients in a clinical study. The combination of 6-cm head elevation with jaw closure using the air-inflatable robotic airbag system decreased upper airway collapsibility (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}\({P}_{_{\text {CRIT}}}\sim -3.4\) \end{document}-cm H\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}\(_{2}\) \end{document}O) compared with the baseline position (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}\({P}_{_{\text {CRIT}}}\sim -0.8\) \end{document}-cm H\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}\(_{2}\) \end{document}O, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}\({P} = 0.0001\) \end{document}). In the clinical study, there was improvement of upper airway obstruction in sleep apnea patients, including decreased apnea and hypopnea duration and increased the lowest level of oxygen saturation. We demonstrated that establishment of head elevation with jaw closure achieved by a remote-controlled airbag device using an inflatable airbag system can produce substantial decreases in upper airway collapsibility and maintain upper airway patency during propofol anesthesia and sleep.

Approach for streamlining measurement of complex physiological phenotypes of upper airway collapsibility

The critical closing pressure (PCRIT), a quantitative assessment of upper airway collapsibility, is derived from pressure flow relationship during sleep. The analytic generation of the pressure flow relationships are non-standardized due to various regression models (linear, spline, median), breath characteristics (flow limited, non-flow limited) or known covariates (sleep stage, body position). We propose a GUI based PCRIT Analysis Software (PAS) to streamline PCRIT analysis and validate its reliability and accuracy compared to current analysis procedures.

METHODS

Seventeen subjects underwent a physiology sleep study in which the PCRIT was determined during NREM sleep. Data analysis was performed independently using three paradigms: (1) PAS (Igor Pro; median regression), (2) non-graphic statistics application (SAS; spline regression), and (3) manual spreadsheet calculations (Excel; linear regression). The reliability and accuracy of the PAS was examined through the agreement between each approach using Bland-Altman plots of the mean difference and within-individual variation using intra-class correlation (ICC).

RESULTS

There was no difference in the group mean values for PCRIT using the PAS (-1.7 ± 0.7 cm H2O) compared to spline regression (-1.6 ± 0.7 cm H2O; p=0.69) or linear regression (-2.1 ± 0.7 cm H2O; p=0.92). The Bland-Altman analysis did not demonstrate a systematic bias between the PAS and either approach. There was a mean difference of 0.39 ± 0.2 cm H2O between the PAS and linear regression approaches, with upper and lower limits of agreement of 1.81 and -1.02 cm H2O, respectively. The PAS and spline analyses demonstrated an even smaller mean difference of -0.10 ± 0.1cm H2O, with upper and lower limits of 0.90 and -1.08 cm H2O, respectively.

CONCLUSION

PAS preserves the reliability and accuracy of the original PCRIT analysis methods while vastly improving their efficiency through graphic user interface and automation of analytic processes. Providing a standardized platform for physiologic data processing offers the ability to implement quality assurance and control procedures for multicenter studies as well as cost saving by improving the efficiency of complex repetitive tasks.

Effect of head elevation on passive upper airway collapsibility in normal subjects during propofol anesthesia

BACKGROUND

Head elevation can restore airway patency during anesthesia, although its effect may be offset by concomitant bite opening or accidental neck flexion. The aim of this study is to examine the effect of head elevation on the passive upper airway collapsibility during propofol anesthesia.

METHOD

Twenty male subjects were studied, randomized to one of two experimental groups: fixed-jaw or free-jaw. Propofol infusion was used for induction and to maintain blood at a constant target concentration between 1.5 and 2.0 μg/ml. Nasal mask pressure (PN) was intermittently reduced to evaluate the upper airway collapsibility (passive PCRIT) and upstream resistance (RUS) at each level of head elevation (0, 3, 6, and 9 cm). The authors measured the Frankfort plane (head flexion) and the mandible plane (jaw opening) angles at each level of head elevation. Analysis of variance was used to determine the effect of head elevation on PCRIT, head flexion, and jaw opening within each group.

RESULTS

In both groups the Frankfort plane and mandible plane angles increased with head elevation (P < 0.05), although the mandible plane angle was smaller in the free-jaw group (i.e., increased jaw opening). In the fixed-jaw group, head elevation decreased upper airway collapsibility (PCRIT ~ -7 cm H₂O at greater than 6 cm elevation) compared with the baseline position (PCRIT ~ -3 cm H₂O at 0 cm elevation; P < 0.05).

CONCLUSION

: Elevating the head position by 6 cm while ensuring mouth closure (centric occlusion) produces substantial decreases in upper airway collapsibility and maintains upper airway patency during anesthesia.

Nasal dilator strips increase maximum inspiratory flow via nasal wall stabilization

OBJECTIVE

Inspiratory flow limitation associated with collapse of the nasal vestibular walls is a feature of nasal breathing at high ventilatory levels. We examined whether an external nasal dilator strip (ENDS) device (Breathe Right, CNS Inc., Chanhassen, MN) influences maximum inspiratory and expiratory flow rates.

STUDY DESIGN

Prospective, randomized.

METHODS

We studied 20 Caucasian subjects (13 female, 7 male; age range, 16-49 y) performing maximum-effort nasal flow-volume loop studies with (ENDS) and without ENDS (control) and following topical nasal decongestant (oxymetazoline hydrochloride, 0.2 mg per nostril).

RESULTS

ENDS increased peak inspiratory flow from 2.55+/-0.24 L/s (mean+/-standard error [SE]) to 2.86+/-0.25 L/s and forced inspiratory flow at 50% of vital capacity from 2.23+/-0.24 L/s to 2.53+/-0.24 L/s (both, P<.0001), but had no effect on maximum expiratory flows. Nasal decongestant increased the forced expiratory volume in 1 second from 3.39+/-0.22 L/s to 3.59+/-0.22 L/s and the average forced expiratory flow over 25% to 75% of vital capacity from 3.31+/-0.31 L/s to 3.61+/-0.28 L/s (both, P< or = .008), but had no effect on maximum inspiratory flows. The combination of decongestant and ENDS increased both inspiratory and expiratory maximum flows.

CONCLUSION

Since ENDS selectively increases maximum nasal inspiratory flow rates, we conclude that ENDS increases inspiratory nasal patency during maximum inspiratory efforts through the nose by supporting the lateral nasal vestibular walls and making them more resistant to collapse.

Effect of alae nasi activation on maximal nasal inspiratory airflow in humans

The upper airway is a complicated structure that is usually widely patent during inspiration. However, on inspiration during certain physiological and pathophysiological states, the nares, pharynx, and larynx may collapse. Collapse at these locations occurs when the transmural pressure (Ptm) at a flow-limiting site (FLS) falls below a critical level (Ptm'). On airway collapse, inspiratory airflow is limited to a maximal level (VImax) determined by (-Ptm')/Rus, where Rus is the resistance upstream to the FLS. The airflow dynamics of the upper airway are affected by the activity of its associated muscles. In this study, we examine the modulation of VImax by muscle activity in the nasal airway under conditions of inspiratory airflow limitation. Each of six subjects performed sniffs through one patent nostril (pretreated with an alpha agonist) while flaring the nostril at varying levels of dilator muscle (alae nasi) EMG activity (EMGan). For each sniff, we located the nasal FLS with an airway catheter and determined VImax, Ptm', and Rus. Activation of the alae nasi from the lowest to the highest values of EMGan increased VImax from 422 +/- 156 to 753 +/- 291 ml/s (P < 0.01) and decreased Ptm' from -3.6 +/- 3.0 to -6.0 +/- 4.7 cmH2O (P < 0.05). Activation of the alae nasi had no consistent effect on Rus. VImax was positively correlated with EMGan, and Ptm' was negatively correlated with EMGan in all subjects. Our findings demonstrate that alae nasi activation increases VImax through the nasal airway by decreasing airway collapsibility.