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Tatkov S, Rees M, Gulley A, van den Heuij LGT, Nilius G. Asymmetrical nasal high flow ventilation improves clearance of CO 2 from the anatomical dead space and increases positive airway pressure. J Appl Physiol (1985) 2023; 134:365-377. [PMID: 36633864 PMCID: PMC9886347 DOI: 10.1152/japplphysiol.00692.2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Positive airway pressure that dynamically changes with breathing, and clearance of anatomical dead space are the key mechanisms of noninvasive respiratory support with nasal high flow (NHF). Pressure mainly depends on flow rate and nare occlusion. The hypothesis is that an increase in asymmetrical occlusion of the nares leads to an improvement in dead-space clearance resulting in a reduction in re-breathing. Clearance was investigated with volumetric capnography in an adult upper-airway model, which was ventilated by a lung simulator with entrained carbon dioxide (CO2) at respiratory rates (RR) of 15-45 min-1 and at 18 min-1 with chronic obstructive pulmonary disease (COPD) breathing patterns. Clearance was assessed at NHF of 20-60 L/min with a symmetrical interface (SI) and an asymmetrical interface (AI). CO2 kinetics visualized by infrared spectroscopy and mathematical modeling were used to study the mechanisms of clearance. At a higher RR (35 min-1) and NHF of 60 L/min, clearance in the upper airway was significantly higher with the AI when compared with the SI (29.64 ± 9.96%, P < 0.001), as opposed to at a lower RR (15 min-1) (1.40 ± 6.25%, P > 0.05), (means ± SD). With COPD breathing, clearance by NHF was reduced but significantly improved with the AI by 45.93% relative to the SI at NHF 20 L/min (P < 0.0001). The maximum pressure achieved with the AI was 6.6 cmH2O and NHF was 60 L/min at the end of expiration. Pressure differences between nasal cavities led to the reverse flow observed in the optical model. Asymmetrical NHF increases dead-space clearance by reverse flow through the choanae and accelerates purging of expired gas via the less occluded nare.NEW & NOTEWORTHY The asymmetrical interface generated reverse flow in the nasal cavities and across the choana, which led to unidirectional purging of expired gas from the upper airways. This accelerated the clearance of anatomical dead space and reduced re-breathing while increased resistance to flow resulted in higher positive end-expiratory pressure (PEEP). These findings are relevant to patients with elevated respiratory rates or with expiratory flow limitations where dead-space clearance by NHF can be substantially reduced.
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Affiliation(s)
| | - Monique Rees
- 1Fisher & Paykel Healthcare Ltd., Auckland, New Zealand
| | - Anton Gulley
- 1Fisher & Paykel Healthcare Ltd., Auckland, New Zealand
| | | | - Georg Nilius
- 2Evang. Kliniken Essen-Mitte GmbH, Essen, Germany,3Universität Witten/Herdecke, Witten, Germany
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Bruni A, Garofalo E, Procopio D, Corrado S, Caroleo A, Biamonte E, Pelaia C, Longhini F. Current Practice of High Flow through Nasal Cannula in Exacerbated COPD Patients. Healthcare (Basel) 2022; 10:536. [PMID: 35327014 PMCID: PMC8954797 DOI: 10.3390/healthcare10030536] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 03/14/2022] [Accepted: 03/14/2022] [Indexed: 11/16/2022] Open
Abstract
Acute Exacerbation of Chronic Obstructive Pulmonary Disease is a form of severe Acute Respiratory Failure (ARF) requiring Conventional Oxygen Therapy (COT) in the case of absence of acidosis or the application of Non-Invasive Ventilation (NIV) in case of respiratory acidosis. In the last decade, High Flow through Nasal Cannula (HFNC) has been increasingly used, mainly in patients with hypoxemic ARF. However, some studies were also published in AECOPD patients, and some evidence emerged. In this review, after describing the mechanism underlying potential clinical benefits, we analyzed the possible clinical application of HFNC to AECOPD patients. In the case of respiratory acidosis, the gold-standard treatment remains NIV, supported by strong evidence in favor. However, HFNC may be considered as an alternative to NIV if the latter fails for intolerance. HFNC should also be considered and preferred to COT at NIV breaks and weaning. Finally, HFNC should also be preferred to COT as first-line oxygen treatment in AECOPD patients without respiratory acidosis.
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Affiliation(s)
| | | | | | | | | | | | | | - Federico Longhini
- Anesthesia and Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, 88100 Catanzaro, Italy; (A.B.); (E.G.); (D.P.); (S.C.); (A.C.); (E.B.); (C.P.)
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Comparison of a simplified nasal continuous positive airways pressure device with nasal cannula in obese patients undergoing colonoscopy during deep sedation: A randomised clinical trial. Eur J Anaesthesiol 2020; 36:633-640. [PMID: 31313720 DOI: 10.1097/eja.0000000000001052] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Continuous positive airways pressure (CPAP) with a CPAP machine and mask has been shown to be more effective at minimising hypoxaemia than other devices under deep sedation. However, the efficacy of a new and simple CPAP device for spontaneously breathing obese patients during colonoscopy is unknown. OBJECTIVE We hypothesised that oxygenation and ventilation in obese patients under deep sedation during colonoscopy using CPAP via a new nasal mask (SuperNO2VA) would be better than routine care with oxygen supplementation via a nasal cannula. DESIGN Randomised study. SETTING Single-centre, June 2017 to October 2017. PATIENTS A total of 174 patients were enrolled and randomly assigned to Mask group or Control group. Thirty-eight patients were excluded and data from 136 patients underwent final analysis. INTERVENTION Patients in the Mask group were provided with nasal CPAP (10 cmH2O) at an oxygen flow rate of 15 l min. In the Control group, patients were given oxygen via a nasal cannula at a flow rate of 5 l min. MAIN OUTCOME MEASURES The primary outcome was elapsed time from anaesthesia induction to the first airway intervention. RESULTS The elapsed time from anaesthesia induction to the first airway intervention was 19 ± 10 min in the Mask group (n=63) vs. 10 ± 12 min in the Control group (n=73, P < 0.001). In all, 87.5% (56/64) of patients achieved the target CPAP value. More patients in the Control group (63%) received airway intervention than in the Mask group (22%) (P < 0.001). Hypoxaemia (pulse oximeter oxygen saturation, SpO2 < 90%) occurred more frequently in the Control group (22%) than in the Mask group (5%) (P = 0.004). Minute ventilationPostinduction/minute ventilationBaseline and minute ventilationProcedure-end/minute ventilationBaseline was lower in the Control group than in the Mask group (P = 0.007 and 0.001, respectively). CONCLUSION Application of a nasal mask at a target CPAP of 10 cmH2O improves ventilation and decreases the frequency and severity of hypoxaemia. TRIAL REGISTRATION NCT03139448, registered at ClinicalTrials.gov.
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Bruni A, Garofalo E, Cammarota G, Murabito P, Astuto M, Navalesi P, Luzza F, Abenavoli L, Longhini F. High Flow Through Nasal Cannula in Stable and Exacerbated Chronic Obstructive Pulmonary Disease Patients. Rev Recent Clin Trials 2020; 14:247-260. [PMID: 31291880 DOI: 10.2174/1574887114666190710180540] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 06/19/2019] [Accepted: 06/20/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND High-Flow through Nasal Cannula (HFNC) is a system delivering heated humidified air-oxygen mixture at a flow up to 60 L/min. Despite increasing evidence in hypoxemic acute respiratory failure, a few is currently known in chronic obstructive pulmonary disease (COPD) patients. OBJECTIVE To describe the rationale and physiologic advantages of HFNC in COPD patients, and to systematically review the literature on the use of HFNC in stable and exacerbated COPD patients, separately. METHODS A search strategy was launched on MEDLINE. Two authors separately screened all potential references. All (randomized, non-randomized and quasi-randomized) trials dealing with the use of HFNC in both stable and exacerbated COPD patients in MEDLINE have been included in the review. RESULTS Twenty-six studies have been included. HFNC: 1) provides heated and humidified airoxygen admixture; 2) washes out the anatomical dead space of the upper airway; 3) generates a small positive end-expiratory pressure; 4) guarantees a more stable inspired oxygen fraction, as compared to conventional oxygen therapy (COT); and 5) is more comfortable as compared to both COT and non-invasive ventilation (NIV). In stable COPD patients, HFNC improves gas exchange, the quality of life and dyspnea with a reduced cost of muscle energy expenditure, compared to COT. In exacerbated COPD patients, HFNC may be an alternative to NIV (in case of intolerance) and to COT at extubation or NIV withdrawal. CONCLUSION Though evidence of superiority still lacks and further studies are necessary, HFNC might play a role in the treatment of both stable and exacerbated COPD patients.
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Affiliation(s)
- Andrea Bruni
- Department of Medical and Surgical Sciences, Intensive Care Unit, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Eugenio Garofalo
- Department of Medical and Surgical Sciences, Intensive Care Unit, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Gianmaria Cammarota
- Anesthesia and Intensive Care, "Maggiore della Carita" Hospital, Novara, Italy
| | - Paolo Murabito
- Department of Anesthesia and Intensive Care, A.O.U. "Policlinico -Vittorio Emanuele", Catania, Italy
| | - Marinella Astuto
- Department of Anesthesia and Intensive Care, A.O.U. "Policlinico -Vittorio Emanuele", Catania, Italy
| | - Paolo Navalesi
- Department of Medical and Surgical Sciences, Intensive Care Unit, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Francesco Luzza
- Department of Health Sciences, University of Catanzaro "Magna Graecia", Viale Europa, 88100 Catanzaro, Italy
| | - Ludovico Abenavoli
- Department of Health Sciences, University of Catanzaro "Magna Graecia", Viale Europa, 88100 Catanzaro, Italy
| | - Federico Longhini
- Department of Medical and Surgical Sciences, Intensive Care Unit, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
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Natalini D, Grieco DL, Santantonio MT, Mincione L, Toni F, Anzellotti GM, Eleuteri D, Di Giannatale P, Antonelli M, Maggiore SM. Physiological effects of high-flow oxygen in tracheostomized patients. Ann Intensive Care 2019; 9:114. [PMID: 31591659 PMCID: PMC6779681 DOI: 10.1186/s13613-019-0591-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 09/30/2019] [Indexed: 01/22/2023] Open
Abstract
Background High-flow oxygen therapy via nasal cannula (HFOTNASAL) increases airway pressure, ameliorates oxygenation and reduces work of breathing. High-flow oxygen can be delivered through tracheostomy (HFOTTRACHEAL), but its physiological effects have not been systematically described. We conducted a cross-over study to elucidate the effects of increasing flow rates of HFOTTRACHEAL on gas exchange, respiratory rate and endotracheal pressure and to compare lower airway pressure produced by HFOTNASAL and HFOTTRACHEAL. Methods Twenty-six tracheostomized patients underwent standard oxygen therapy through a conventional heat and moisture exchanger, and then HFOTTRACHEAL through a heated humidifier, with gas flow set at 10, 30 and 50 L/min. Each step lasted 30 min; gas flow sequence during HFOTTRACHEAL was randomized. In five patients, measurements were repeated during HFOTTRACHEAL before tracheostomy decannulation and immediately after during HFOTNASAL. In each step, arterial blood gases, respiratory rate, and tracheal pressure were measured. Results During HFOTTRACHEAL, PaO2/FiO2 ratio and tracheal expiratory pressure slightly increased proportionally to gas flow. The mean [95% confidence interval] expiratory pressure raise induced by 10-L/min increase in flow was 0.2 [0.1–0.2] cmH2O (ρ = 0.77, p < 0.001). Compared to standard oxygen, HFOTTRACHEAL limited the negative inspiratory swing in tracheal pressure; at 50 L/min, but not with other settings, HFOTTRACHEAL increased mean tracheal expiratory pressure by (mean difference [95% CI]) 0.4 [0.3–0.6] cmH2O, peak tracheal expiratory pressure by 0.4 [0.2–0.6] cmH2O, improved PaO2/FiO2 ratio by 40 [8–71] mmHg, and reduced respiratory rate by 1.9 [0.3–3.6] breaths/min without PaCO2 changes. As compared to HFOTTRACHEAL, HFOTNASAL produced higher tracheal mean and peak expiratory pressure (at 50 L/min, mean difference [95% CI]: 3 [1–5] cmH2O and 4 [1–7] cmH2O, respectively). Conclusions As compared to standard oxygen, 50 L/min of HFOTTRACHEAL are needed to improve oxygenation, reduce respiratory rate and provide small degree of positive airway expiratory pressure, which, however, is significantly lower than the one produced by HFOTNASAL.
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Affiliation(s)
- Daniele Natalini
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, Rome, Italy
| | - Domenico L Grieco
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, Rome, Italy
| | - Maria Teresa Santantonio
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, Rome, Italy
| | - Lucrezia Mincione
- Department of Medical, Oral and Biotechnological Sciences, School of Medicine and Health Sciences, Section of Anesthesia Analgesia, Perioperative and Intensive Care, SS. Annunziata Hospital, Gabriele d'Annunzio University of Chieti-Pescara, Via dei Vestini, 66100, Chieti, Italy
| | - Flavia Toni
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, Rome, Italy
| | - Gian Marco Anzellotti
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, Rome, Italy
| | - Davide Eleuteri
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, Rome, Italy
| | - Pierluigi Di Giannatale
- Department of Medical, Oral and Biotechnological Sciences, School of Medicine and Health Sciences, Section of Anesthesia Analgesia, Perioperative and Intensive Care, SS. Annunziata Hospital, Gabriele d'Annunzio University of Chieti-Pescara, Via dei Vestini, 66100, Chieti, Italy
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, Rome, Italy
| | - Salvatore Maurizio Maggiore
- Department of Medical, Oral and Biotechnological Sciences, School of Medicine and Health Sciences, Section of Anesthesia Analgesia, Perioperative and Intensive Care, SS. Annunziata Hospital, Gabriele d'Annunzio University of Chieti-Pescara, Via dei Vestini, 66100, Chieti, Italy.
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Sukul P, Oertel P, Kamysek S, Trefz P. Oral or nasal breathing? Real-time effects of switching sampling route onto exhaled VOC concentrations. J Breath Res 2017; 11:027101. [DOI: 10.1088/1752-7163/aa6368] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Chen L, Li HL, Brochard L. High-flow nasal cannula in postextubation management. J Thorac Dis 2016; 8:E1013-E1016. [PMID: 27747049 DOI: 10.21037/jtd.2016.08.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Lu Chen
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada;; Keenan Research Centre and Li Ka Shing Knowledge Institute, Department of Critical Care, St Michael's Hospital, Toronto, Canada
| | - Hong-Liang Li
- Keenan Research Centre and Li Ka Shing Knowledge Institute, Department of Critical Care, St Michael's Hospital, Toronto, Canada;; Department of Critical Care Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada;; Keenan Research Centre and Li Ka Shing Knowledge Institute, Department of Critical Care, St Michael's Hospital, Toronto, Canada
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Möller W, Celik G, Feng S, Bartenstein P, Meyer G, Oliver E, Schmid O, Tatkov S. Nasal high flow clears anatomical dead space in upper airway models. J Appl Physiol (1985) 2016; 118:1525-32. [PMID: 25882385 PMCID: PMC4482836 DOI: 10.1152/japplphysiol.00934.2014] [Citation(s) in RCA: 170] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Recent studies showed that nasal high flow (NHF) with or without supplemental oxygen can assist ventilation of patients with chronic respiratory and sleep disorders. The hypothesis of this study was to test whether NHF can clear dead space in two different models of the upper nasal airways. The first was a simple tube model consisting of a nozzle to simulate the nasal valve area, connected to a cylindrical tube to simulate the nasal cavity. The second was a more complex anatomically representative upper airway model, constructed from segmented CT-scan images of a healthy volunteer. After filling the models with tracer gases, NHF was delivered at rates of 15, 30, and 45 l/min. The tracer gas clearance was determined using dynamic infrared CO2 spectroscopy and 81mKr-gas radioactive gamma camera imaging. There was a similar tracer-gas clearance characteristic in the tube model and the upper airway model: clearance half-times were below 1.0 s and decreased with increasing NHF rates. For both models, the anterior compartments demonstrated faster clearance levels (half-times < 0.5 s) and the posterior sections showed slower clearance (half-times < 1.0 s). Both imaging methods showed similar flow-dependent tracer-gas clearance in the models. For the anatomically based model, there was complete tracer-gas removal from the nasal cavities within 1.0 s. The level of clearance in the nasal cavities increased by 1.8 ml/s for every 1.0 l/min increase in the rate of NHF. The study has demonstrated the fast-occurring clearance of nasal cavities by NHF therapy, which is capable of reducing of dead space rebreathing.
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Maggiore SM, Idone FA, Vaschetto R, Festa R, Cataldo A, Antonicelli F, Montini L, De Gaetano A, Navalesi P, Antonelli M. Nasal High-Flow versus Venturi Mask Oxygen Therapy after Extubation. Effects on Oxygenation, Comfort, and Clinical Outcome. Am J Respir Crit Care Med 2014; 190:282-8. [DOI: 10.1164/rccm.201402-0364oc] [Citation(s) in RCA: 317] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Mündel T, Feng S, Tatkov S, Schneider H. Mechanisms of nasal high flow on ventilation during wakefulness and sleep. J Appl Physiol (1985) 2013; 114:1058-65. [PMID: 23412897 DOI: 10.1152/japplphysiol.01308.2012] [Citation(s) in RCA: 113] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Nasal high flow (NHF) has been shown to increase expiratory pressure and reduce respiratory rate but the mechanisms involved remain unclear. Ten healthy participants [age, 22 ± 2 yr; body mass index (BMI), 24 ± 2 kg/m(2)] were recruited to determine ventilatory responses to NHF of air at 37°C and fully saturated with water. We conducted a randomized, controlled, cross-over study consisting of four separate ∼60-min visits, each 1 wk apart, to determine the effect of NHF on ventilation during wakefulness (NHF at 0, 15, 30, and 45 liters/min) and sleep (NHF at 0, 15, and 30 liters/min). In addition, a nasal cavity model was used to compare pressure/air-flow relationships of NHF and continuous positive airway pressure (CPAP) throughout simulated breathing. During wakefulness, NHF led to an increase in tidal volume from 0.7 ± 0.1 liter to 0.8 ± 0.2, 1.0 ± 0.2, and 1.3 ± 0.2 liters, and a reduction in respiratory rate (fR) from 16 ± 2 to 13 ± 3, 10 ± 3, and 8 ± 3 breaths/min (baseline to 15, 30, and 45 liters/min NHF, respectively; P < 0.01). In contrast, during sleep, NHF led to a ∼20% fall in minute ventilation due to a decrease in tidal volume and no change in fR. In the nasal cavity model, NHF increased expiratory but decreased inspiratory resistance depending on both the cannula size and the expiratory flow rate. The mechanisms of action for NHF differ from those of CPAP and are sleep/wake-state dependent. NHF may be utilized to increase tidal breathing during wakefulness and to relieve respiratory loads during sleep.
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Affiliation(s)
- Toby Mündel
- School of Sport and Exercise, Massey University, Palmerston North, New Zealand
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Current world literature. Curr Opin Allergy Clin Immunol 2010; 10:87-92. [PMID: 20026987 DOI: 10.1097/aci.0b013e3283355458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Busha BF, Hage E, Hofmann C. Gender and breathing route modulate cardio-respiratory variability in humans. Respir Physiol Neurobiol 2009; 166:87-94. [PMID: 19429524 DOI: 10.1016/j.resp.2009.02.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2008] [Revised: 02/15/2009] [Accepted: 02/16/2009] [Indexed: 01/26/2023]
Abstract
During spontaneous breathing, there is an intrinsic scaling of respiratory variability and a correlation between respiratory and heart rate variabilities. To identify the effect of breathing route on respiratory and heart rate variabilities, breath-to-breath interval (BBI) and heartbeat-to-heartbeat interval (RRI) were recorded from 12 female and 12 male adult subjects breathing through the nose or mouth. Temporal scaling within the BBI and RRI was quantified with detrended fluctuation analysis (DFA). We identified a significant gender-based breathing route interaction in the short-term scaling of BBI (p=0.007), a decrease in the short-term scaling of RRI during nose breathing (p=0.026), and a significant interdependence of short-term scaling of BBI and RRI in female subjects. We conclude that there is a gender-based differential effect of breathing route on the control of respiration and an increase in the random behavior of RRI associated with nasal breathing. These data also suggest the presence cardio-respiratory coupling of scaling behavior in female subjects.
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Affiliation(s)
- Brett F Busha
- Department of Electrical and Computer Engineering, The College of New Jersey, NJ 08628, United States.
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Hillegass EA. Breathing retraining for individuals with chronic obstructive pulmonary disease--a role for clinicians. Chron Respir Dis 2009; 6:43-4. [PMID: 19176711 DOI: 10.1177/1479972308098670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- E A Hillegass
- Department of Physical Therapy, Adjunct Faculty North Georgia College and State University, Dahlonega, Georgia, USA.
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