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Bizzotto D, Dahl MJ, Veneroni C, Lavizzari A, Rebentisch A, Dawson E, Bowen S, Zuspan K, Yoder BA, Albertine KH, Dellacà RL. Impact of neonatal noninvasive resuscitation strategies on lung mechanics, tracheal pressure, and tidal volume in preterm lambs. Am J Physiol Lung Cell Mol Physiol 2024; 327:L203-L217. [PMID: 38771135 DOI: 10.1152/ajplung.00236.2022] [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: 07/25/2022] [Revised: 05/15/2024] [Accepted: 05/15/2024] [Indexed: 05/22/2024] Open
Abstract
This study investigated the relationship between three respiratory support approaches on lung volume recruitment during the first 2 h of postnatal life in preterm lambs. We estimated changes in lung aeration, measuring respiratory resistance and reactance by oscillometry at 5 Hz. We also measured intratracheal pressure in subsets of lambs. The first main finding is that sustained inflation (SI) applied noninvasively (Mask SI; n = 7) or invasively [endotracheal tube (ETT) SI; n = 6] led to similar rapid lung volume recruitment (∼6 min). In contrast, Mask continuous positive airway pressure (CPAP) without SI (n = 6) resuscitation took longer (∼30-45 min) to reach similar lung volume recruitment. The second main finding is that, in the first 15 min of postnatal life, the Mask CPAP without SI group closed their larynx during custom ventilator-driven expiration, leading to intratracheal positive end-expiratory pressure of ∼17 cmH2O (instead of 8 cmH2O provided by the ventilator). In contrast, the Mask SI group used the larynx to limit inspiratory pressure to ∼26 cmH2O (instead of 30 cmH2O provided by the ventilator). These different responses affected tidal volume, being larger in the Mask CPAP without SI group [8.4 mL/kg; 6.7-9.3 interquartile range (IQR)] compared to the Mask SI (5.0 mL/kg; 4.4-5.2 IQR) and ETT SI groups (3.3 mL/kg; 2.6-3.7 IQR). Distinct physiological responses suggest that spontaneous respiratory activity of the larynx of preterm lambs at birth can uncouple pressure applied by the ventilator to that applied to the lung, leading to unpredictable lung pressure and tidal volume delivery independently from the ventilator settings.NEW & NOTEWORTHY We compared invasive and noninvasive resuscitation on lambs at birth, including or not sustained inflation (SI). Lung volume recruitment was faster in those receiving SI. During noninvasive resuscitation, larynx modulation reduced tracheal pressure from that applied to the mask in lambs receiving SI, while it led to increased auto-positive end-expiratory pressure and very large tidal volumes in lambs not receiving SI. Our results highlight the need for individualizing pressures and monitoring tidal volumes during resuscitation at birth.
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Affiliation(s)
- Davide Bizzotto
- TechRes Lab, Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano University, Milan, Italy
| | - Mar Janna Dahl
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Chiara Veneroni
- TechRes Lab, Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano University, Milan, Italy
| | - Anna Lavizzari
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrew Rebentisch
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Elaine Dawson
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Sydney Bowen
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Kaitlin Zuspan
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Bradley A Yoder
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Kurt H Albertine
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Raffaele L Dellacà
- TechRes Lab, Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano University, Milan, Italy
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Mukerji A, Keszler M. Continuous Positive Airway Pressure versus Nasal Intermittent Positive Pressure Ventilation in Preterm Neonates: What if Mean Airway Pressures were Equivalent? Am J Perinatol 2024. [PMID: 38211631 DOI: 10.1055/a-2242-7391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
Respiratory support for preterm neonates in modern neonatal intensive care units is predominantly with the use of noninvasive interfaces. Continuous positive airway pressure (CPAP) and nasal intermittent positive pressure ventilation (NIPPV) are the prototypical and most commonly utilized forms of noninvasive respiratory support, and each has unique gas flow characteristics. In meta-analyses of clinical trials till date, NIPPV has been shown to likely reduce respiratory failure and need for intubation compared to CPAP. However, a significant limitation of the included studies has been the higher mean airway pressures used during NIPPV. Thus, it is unclear to what extent any benefits seen with NIPPV are due to the cyclic pressure application versus the higher mean airway pressures. In this review, we elaborate on these limitations and summarize the available evidence comparing NIPPV and CPAP at equivalent mean airway pressures. Finally, we call for further studies comparing noninvasive respiratory support modes at equal mean airway pressures. KEY POINTS: · Most current literature on CPAP vs. NIPPV in preterm neonates is confounded by use of higher mean airway pressures during NIPPV.. · In this review, we summarize existing evidence on CPAP vs. NIPPV at equivalent mean airway pressures.. · We call for future research on noninvasive support modes to account for mean airway pressures..
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Affiliation(s)
- Amit Mukerji
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Martin Keszler
- Department of Pediatrics, Brown University, Providence, Rhode Island
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Koh J, Phyland D, Baxter M, Leong P, Bardin PG. Vocal cord dysfunction/inducible laryngeal obstruction: novel diagnostics and therapeutics. Expert Rev Respir Med 2023; 17:429-445. [PMID: 37194252 DOI: 10.1080/17476348.2023.2215434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 05/15/2023] [Indexed: 05/18/2023]
Abstract
INTRODUCTION Vocal cord dysfunction/inducible laryngeal obstruction (VCD/ILO) is an important medical condition but understanding of the condition is imperfect. It occurs in healthy people but often co-exists with asthma. Models of VCD/ILO pathophysiology highlight predisposing factors rather than specific mechanisms and disease expression varies between people, which is seldom appreciated. Diagnosis is often delayed, and the treatment is not evidence based. AREAS COVERED A unified pathophysiological model and disease phenotypes have been proposed. Diagnosis is conventionally made by laryngoscopy during inspiration with vocal cord narrowing >50% Recently, dynamic CT larynx was shown to have high specificity (>80%) with potential as a noninvasive, swift, and quantifiable diagnostic modality. Treatment entails laryngeal retraining with speech pathology intervention and experimental therapies such as botulinum toxin injection. Multidisciplinary team (MDT) clinics are a novel innovation with demonstrated benefits including accurate diagnosis, selection of appropriate treatment, and reductions in oral corticosteroid exposure. EXPERT OPINION Delayed diagnosis of VCD/ILO is pervasive, often leading to detrimental treatments. Phenotypes require validation and CT larynx can reduce the necessity for laryngoscopy, thereby fast-tracking diagnosis. MDT clinics can optimize management. Randomized controlled trials are essential to validate speech pathology intervention and other treatment modalities and to establish international standards of care.
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Affiliation(s)
- Joo Koh
- Monash Health Department of Otolaryngology, Head and Neck Surgery, Monash Hospital and University, Melbourne, Australia
- Monash Lung Sleep Allergy & Immunology, Monash Hospital and University, Melbourne, Australia
| | - Debra Phyland
- Monash Health Department of Otolaryngology, Head and Neck Surgery, Monash Hospital and University, Melbourne, Australia
- School of Clinical Sciences, Faculty of Medicine, Nursing & Health Sciences, Monash University, Melbourne, Australia
| | - Malcolm Baxter
- Monash Health Department of Otolaryngology, Head and Neck Surgery, Monash Hospital and University, Melbourne, Australia
- Monash Lung Sleep Allergy & Immunology, Monash Hospital and University, Melbourne, Australia
| | - Paul Leong
- Monash Lung Sleep Allergy & Immunology, Monash Hospital and University, Melbourne, Australia
- Hudson Institute, Monash Hospital and University, Melbourne, Australia
| | - Philip G Bardin
- Monash Lung Sleep Allergy & Immunology, Monash Hospital and University, Melbourne, Australia
- Hudson Institute, Monash Hospital and University, Melbourne, Australia
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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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Low K, Ruane L, Uddin N, Finlay P, Lau KK, Hamza K, Holmes PW, Hamilton G, Bardin PG. Abnormal vocal cord movement in patients with and without airway obstruction and asthma symptoms. Clin Exp Allergy 2016; 47:200-207. [PMID: 27664415 DOI: 10.1111/cea.12828] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 08/24/2016] [Accepted: 08/29/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Abnormal vocal cord movements can cause laryngeal extrathoracic airway obstruction (often called vocal cord dysfunction - VCD) leading to asthma-like symptoms. These aberrant movements are characteristically present during inspiration and termed paradoxical vocal cord movement (PVCM). We have reported PVCM in up to 40% of severe asthmatics, but it is not known if PVCM is detectable in all patients with asthma-like symptoms and if the condition is more often associated with abnormal lung function. OBJECTIVE We hypothesized that PVCM is frequently associated with asthma symptoms accompanied by airflow limitation. Studies examined whether PVCM is solely linked to experiencing asthma symptoms, or if PVCM is related to airflow limitation and/or other disease characteristics. METHODS Patients with asthma symptoms were recruited from general practice and severe asthma clinics (n = 155). Pulmonary function measurements were conducted, asthma control and Nijmegen (dysfunctional breathing) questionnaires were administered and skin prick testing was carried out. PVCM was quantified using dynamic 320-slice computerized tomography of the larynx. Groups were divided into patients with FEV1 ≥ 80% predicted or FEV1 < 80% predicted and FEV1 /FVC < 0.7. ATS/ERS definitions of severity were also applied and evaluated. Detection of PVCM in the groups was compared and analyses performed to identify features associated with PVCM. RESULTS Overall (n = 155), PVCM was detected in 42 cases (27.1%). Patients with FEV1 < 80% predicted had PVCM more often (25/68, 36.8%) than individuals with normal spirometry (17/87, 19.5%; P = 0.016). PVCM was associated with older age (P = 0.003) and with Nijmegen scores > 20 (P = 0.04). Patients with FEV1 < 80% predicted plus Nijmegen scores > 20 were more likely to have PVCM (OR = 9.3, P = 0.02). CONCLUSIONS AND CLINICAL RELEVANCE Paradoxical vocal cord movement is more often associated with asthma symptoms accompanied by airflow limitation and dysfunctional breathing. Further studies are needed to determine whether PVCM is induced by dysfunctional breathing practices and/or airway obstruction. How PVCM links with symptomatic asthma and VCD also requires evaluation.
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Affiliation(s)
- K Low
- Monash Lung and Sleep, Monash University and Hospital, Melbourne, Vic., Australia.,Hudson Institute, Monash University and Hospital, Melbourne, Vic., Australia
| | - L Ruane
- Monash Lung and Sleep, Monash University and Hospital, Melbourne, Vic., Australia.,Hudson Institute, Monash University and Hospital, Melbourne, Vic., Australia
| | - N Uddin
- Monash Lung and Sleep, Monash University and Hospital, Melbourne, Vic., Australia
| | - P Finlay
- Monash Lung and Sleep, Monash University and Hospital, Melbourne, Vic., Australia
| | - K K Lau
- Diagnostic Imaging, Monash University and Hospital, Melbourne, Vic., Australia
| | - K Hamza
- Statistical Services, Monash University and Hospital, Melbourne, Vic., Australia
| | - P W Holmes
- Monash Lung and Sleep, Monash University and Hospital, Melbourne, Vic., Australia
| | - G Hamilton
- Monash Lung and Sleep, Monash University and Hospital, Melbourne, Vic., Australia.,Hudson Institute, Monash University and Hospital, Melbourne, Vic., Australia
| | - P G Bardin
- Monash Lung and Sleep, Monash University and Hospital, Melbourne, Vic., Australia.,Hudson Institute, Monash University and Hospital, Melbourne, Vic., Australia
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Abstract
Non-invasive ventilation (NIV) is used in neonates to treat extrathoracic and intrathoracic airway obstruction, parenchymal lung disease and disorders of control of breathing. Avoidance of airway intubation is associated with a reduction in the incidence of chronic lung disease among preterm infants with respiratory distress syndrome. Use of nasal continuous positive airway pressure (nCPAP) may help establish and maintain functional residual capacity (FRC), decrease respiratory work, and improve gas exchange. Other modes of non-invasive ventilation, which include heated humidified high-flow nasal cannula therapy (HHHFNC), nasal intermittent mandatory ventilation (NIMV), non-invasive pressure support ventilation (NI-PSV), and bi-level CPAP (SiPAP™), have also been shown to provide additional benefit in improving breathing patterns, reducing work of breathing, and increasing gas exchange when compared with nCPAP. Newer modes, such as neurally adjusted ventilatory assist (NAVA), hold the promise of improving patient-ventilator synchrony and so might ultimately improve outcomes for preterm infants with respiratory distress.
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Affiliation(s)
- Stamatia Alexiou
- Division of Pulmonary Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Howard B Panitch
- The Perelman School of Medicine at The University of Pennsylvania, Division of Pulmonary Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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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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Aboussouan LS. Sleep-disordered Breathing in Neuromuscular Disease. Am J Respir Crit Care Med 2015; 191:979-89. [DOI: 10.1164/rccm.201412-2224ci] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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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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Hadj-Ahmed MA, Samson N, Nadeau C, Boudaa N, Praud JP. Laryngeal muscle activity during nasal high-frequency oscillatory ventilation in nonsedated newborn lambs. Neonatology 2015; 107:199-205. [PMID: 25660143 DOI: 10.1159/000369120] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 10/14/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND We have previously shown that nasal pressure support ventilation (nPSV) can lead to an active inspiratory laryngeal narrowing in lambs. This, in turn, can limit lung ventilation and divert air into the digestive system, with potentially deleterious consequences. On the other hand, nasal high-frequency oscillatory ventilation (nHFOV) is particularly attractive in newborns, especially since, unlike nPSV, it does not require synchronization with the patient's inspiratory efforts. OBJECTIVES The main aim of the present study was to test the hypothesis that glottal constrictor muscle activity (EMG) does not develop during nHFOV. A secondary objective was to study laryngeal EMG during nHFOV-induced central apneas. METHODS Polysomnographic recordings were performed in 7 nonsedated lambs which were ventilated with increasing levels of nPSV and nHFOV at both 4 and 8 Hz, in random order. States of alertness, diaphragm and glottal muscle EMG, SpO2, and respiratory movements were continuously recorded. RESULTS While phasic inspiratory glottal constrictor EMG appeared with increasing nPSV levels in 6 out of 7 lambs, it was never observed with nHFOV. In addition, nHFOV at 4 Hz dramatically inhibited central respiratory drive in 4/7 lambs, with 64-100% of recording time spent in central apnea in 3 lambs. No glottal constrictor EMG was observed during these central apneas. CONCLUSION nHFOV does not induce glottal constrictor muscle EMG in nonsedated newborn lambs, in contrast to nPSV. This may be an additional advantage of nHFOV relative to nPSV.
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Affiliation(s)
- Mohamed Amine Hadj-Ahmed
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Physiology, Université de Sherbrooke, Sherbrooke, Que., Canada
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Samson N, Niane L, Nault S, Nadeau C, Praud JP. Laryngeal narrowing during nasal ventilation does not originate from bronchopulmonary C-fibers. Respir Physiol Neurobiol 2014; 202:32-4. [PMID: 25075590 DOI: 10.1016/j.resp.2014.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 07/21/2014] [Accepted: 07/22/2014] [Indexed: 11/25/2022]
Abstract
We previously showed that nasal pressure support ventilation (nPSV) can lead to active inspiratory laryngeal narrowing, which originates from the stimulation of bronchopulmonary receptors. Among the three major types of bronchopulmonary receptors, which are variably stimulated by lung distension, C-fiber endings are remarkable, given that their stimulation can also trigger laryngeal closure. Taking advantage of our lamb model with blocked C-fibers, we aimed to assess whether bronchopulmonary C-fiber endings are involved in the active inspiratory laryngeal narrowing during nPSV. Nine lambs were surgically instrumented to assess states of alertness, electrical activity of a glottal constrictor (EaTA), respiratory movements and arterial blood gases. Forty-eight hours later, two polysomnographic recordings were performed during nPSV 15/4 cmH2O, before and after C-fiber blockade. During nPSV, blockade of C-fibers did not prevent inspiratory EaTA (present for 74±41% of respiratory cycles vs. 64±35%, p=0.9). We conclude that active inspiratory laryngeal narrowing during nPSV does not originate from bronchopulmonary C-fiber endings.
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Affiliation(s)
- Nathalie Samson
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Physiology, Université de Sherbrooke, QC, Canada J1H 5N4
| | - Lalah Niane
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Physiology, Université de Sherbrooke, QC, Canada J1H 5N4
| | - Stéphanie Nault
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Physiology, Université de Sherbrooke, QC, Canada J1H 5N4
| | - Charlène Nadeau
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Physiology, Université de Sherbrooke, QC, Canada J1H 5N4
| | - Jean-Paul Praud
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Physiology, Université de Sherbrooke, QC, Canada J1H 5N4.
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Mirabella L, Grasselli G, Haitsma JJ, Zhang H, Slutsky AS, Sinderby C, Beck J. Lung protection during non-invasive synchronized assist versus volume control in rabbits. Crit Care 2014; 18:R22. [PMID: 24456613 PMCID: PMC4057206 DOI: 10.1186/cc13706] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Accepted: 01/14/2014] [Indexed: 11/10/2022] Open
Abstract
Introduction Experimental work provides insight into potential lung protective strategies. The objective of this study was to evaluate markers of ventilator-induced lung injury after two different ventilation approaches: (1) a “conventional” lung-protective strategy (volume control (VC) with low tidal volume, positive end-expiratory pressure (PEEP) and paralysis), (2) a physiological approach with spontaneous breathing, permitting synchrony, variability and a liberated airway. For this, we used non-invasive Neurally Adjusted Ventilatory Assist (NIV-NAVA), with the hypothesis that liberation of upper airways and the ventilator’s integration with lung protective reflexes would be equally lung protective. Methods In this controlled and randomized in vivo laboratory study, 25 adult White New Zealand rabbits were studied, including five non-ventilated control animals. The twenty animals with aspiration-induced lung injury were randomized to ventilation with either VC (6 mL/kg, PEEP 5 cm H2O, and paralysis) or NIV-NAVA for six hours (PEEP = zero because of leaks). Markers of lung function, lung injury, vital signs and ventilator parameters were assessed. Results At the end of six hours of ventilation (n = 20), there were no significant differences between VC and NIV-NAVA for vital signs, PaO2/FiO2 ratio, lung wet-to-dry ratio and broncho-alveolar Interleukin 8 (Il-8). Plasma IL-8 was higher in VC (P <0.05). Lung injury score was lower for NIV-NAVA (P = 0.03). Dynamic lung compliance recovered after six hours in NIV-NAVA but not in VC (P <0.05). During VC, peak pressures increased from 9.2 ± 2.4 cm H2O (hour 1) to 12.3 ± 12.3 cm H2O (hour 6) (P <0.05). During NIV-NAVA, the tracheal end-expiratory pressure was similar to the end-expiratory pressure during VC. Two animals regurgitated during NIV-NAVA, without clinical consequences, and survived the protocol. Conclusions In experimental acute lung injury, NIV-NAVA is as lung-protective as VC 6 ml/kg with PEEP. Electronic supplementary material The online version of this article (doi:10.1186/cc13706) contains supplementary material, which is available to authorized users.
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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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Abstract
Multiple randomized controlled trials have suggested that nasal intermittent positive pressure ventilation, compared with nasal continuous airway pressure, prevents extubation failure and may decrease bronchopulmonary dysplasia. This article summarizes these studies and suggests strategies for the use of nasal intermittent positive pressure ventilation in neonates.
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Affiliation(s)
- Vineet Bhandari
- Division of Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, Yale Child Health Research Center, Room 219, PO Box 208081, 464 Congress Avenue, New Haven, CT 06520, USA.
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15
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Abstract
Protracted mechanical ventilation is associated with increased morbidity and mortality in preterm infants and thus the earliest possible weaning from mechanical ventilation is desirable. Weaning protocols may be helpful in achieving more rapid reduction in support. There is no clear consensus regarding the level of support at which an infant is ready for extubation. An improved ability to predict when a preterm infant has a high likelihood of successful extubation is highly desirable. In this article, available evidence is reviewed and reasonable evidence-based recommendations for expeditious weaning and extubation are provided.
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Affiliation(s)
- G M Sant'Anna
- McGill University Health Center, 2300 Tupper Street, Montreal, Québec, Canada, H3Z1L2
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16
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Hadj-Ahmed MA, Samson N, Bussières M, Beck J, Praud JP. Absence of inspiratory laryngeal constrictor muscle activity during nasal neurally adjusted ventilatory assist in newborn lambs. J Appl Physiol (1985) 2012; 113:63-70. [PMID: 22518828 DOI: 10.1152/japplphysiol.01496.2011] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
In nonsedated newborn lambs, nasal pressure support ventilation (nPSV) can lead to an active glottal closure in early inspiration, which can limit lung ventilation and divert air into the digestive system, with potentially deleterious consequences. During volume control ventilation (nVC), glottal closure is delayed to the end of inspiration, suggesting that it is reflexly linked to the maximum value of inspiratory pressure. Accordingly, the aim of the present study was to test whether inspiratory glottal closure develops at the end of inspiration during nasal neurally adjusted ventilatory assist (nNAVA), an increasingly used ventilatory mode where maximal pressure is also reached at the end of inspiration. Polysomnographic recordings were performed in eight nonsedated, chronically instrumented lambs, which were ventilated with progressively increasing levels of nPSV and nNAVA in random order. States of alertness, diaphragm, and glottal muscle electrical activity, tracheal pressure, Spo(2), tracheal Pet(CO(2)), and respiratory inductive plethysmography were continuously recorded. Although phasic inspiratory glottal constrictor electrical activity appeared during nPSV in 5 of 8 lambs, it was never observed at any nNAVA level in any lamb, even at maximal achievable nNAVA levels. In addition, a decrease in Pco(2) was neither necessary nor sufficient for the development of inspiratory glottal constrictor activity. In conclusion, nNAVA does not induce active inspiratory glottal closure, in contrast to nPSV and nVC. We hypothesize that this absence of inspiratory activity is related to the more physiological airway pressurization during nNAVA, which tightly follows diaphragm electrical activity throughout inspiration.
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Affiliation(s)
- Mohamed Amine Hadj-Ahmed
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Physiology, Université de Sherbrooke, Quebec, Canada
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17
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Samson N, Dumont S, Specq ML, Praud JP. Radio telemetry devices to monitor breathing in non-sedated animals. Respir Physiol Neurobiol 2011; 179:111-8. [PMID: 21964163 DOI: 10.1016/j.resp.2011.09.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Revised: 09/13/2011] [Accepted: 09/16/2011] [Indexed: 11/27/2022]
Abstract
Radio telemetry equipment has significantly improved over the last 10-15 years and is increasingly being used in research for monitoring a variety of physiological parameters in non-sedated animals. The aim of this review is to provide an update on the current state of development of radio telemetry for recording respiration. Our literature review found only rare reports of respiratory studies via radio telemetry. Much of this article will hence report our experience with our custom-built radio telemetry devices designed for recording respiratory signals, together with numerous other physiological signals in lambs. Our current radio telemetry system allows to record 24 simultaneous signals 24h/day for several days. To our knowledge, this is the highest number of physiological signals, which can be recorded wirelessly. Our devices have been invaluable for studying respiration in our ovine models of preterm birth, reflux laryngitis, postnatal exposure to cigarette smoke, respiratory syncytial virus infection and nasal ventilation, all of which are relevant to neonatal respiratory problems.
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Affiliation(s)
- Nathalie Samson
- Neonatal Respiratory Research Unit, Department of Pediatrics and Physiology, Université de Sherbrooke, QC, Canada
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18
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Andersson B, Lundin S, Lindgren S, Stenqvist O, Odenstedt Hergès H. End-expiratory lung volume and ventilation distribution with different continuous positive airway pressure systems in volunteers. Acta Anaesthesiol Scand 2011; 55:157-64. [PMID: 21108619 DOI: 10.1111/j.1399-6576.2010.02337.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Continuous positive airway pressure (CPAP) has been shown to improve oxygenation and a number of different CPAP systems are available. The aim of this study was to assess lung volume and ventilation distribution using three different CPAP techniques. METHODS A high-flow CPAP system (HF-CPAP), an ejector-driven system (E-CPAP) and CPAP using a Servo 300 ventilator (V-CPAP) were randomly applied at 0, 5 and 10 cmH₂O in 14 volunteers. End-expiratory lung volume (EELV) was measured by N₂ dilution at baseline; changes in EELV and tidal volume distribution were assessed by electric impedance tomography. RESULTS Higher end-expiratory and mean airway pressures were found using the E-CPAP vs. the HF-CPAP and the V-CPAP system (P<0.01). EELV increased markedly from baseline, 0 cmH₂O, with increased CPAP levels: 1110±380, 1620±520 and 1130±350 ml for HF-, E- and V-CPAP, respectively, at 10 cmH₂O. A larger fraction of the increase in EELV occurred for all systems in ventral compared with dorsal regions (P<0.01). In contrast, tidal ventilation was increasingly directed toward dorsal regions with increasing CPAP levels (P<0.01). The increase in EELV as well as the tidal volume redistribution were more pronounced with the E-CPAP system as compared with both the HF-CPAP and the V-CPAP systems (P<0.05) at 10 cmH₂O. CONCLUSION EELV increased more in ventral regions with increasing CPAP levels, independent of systems, leading to a redistribution of tidal ventilation toward dorsal regions. Different CPAP systems resulted in different airway pressure profiles, which may result in different lung volume expansion and tidal volume distribution.
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Affiliation(s)
- B Andersson
- Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden.
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19
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de Winter JP, de Vries MAG, Zimmermann LJI. Clinical practice : noninvasive respiratory support in newborns. Eur J Pediatr 2010; 169:777-82. [PMID: 20179966 PMCID: PMC2876262 DOI: 10.1007/s00431-010-1159-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2009] [Accepted: 01/27/2010] [Indexed: 11/04/2022]
Abstract
The most important goal of introducing noninvasive ventilation (NIV) has been to decrease the need for intubation and, therefore, mechanical ventilation in newborns. As a result, this technique may reduce the incidence of bronchopulmonary dysplasia (BPD). In addition to nasal CPAP, improvements in sensors and flow delivery systems have resulted in the introduction of a variety of other types of NIV. For the optimal application of these novelties, a thorough physiological knowledge of mechanics of the respiratory system is necessary. In this overview, the modern insights of noninvasive respiratory therapy in newborns are discussed. These aspects include respiratory support in the delivery room; conventional and modern nCPAP; humidified, heated, and high-flow nasal cannula ventilation; and nasal intermittent positive pressure ventilation. Finally, an algorithm is presented describing common practice in taking care of respiratory distress in prematurely born infants.
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Affiliation(s)
| | | | - Luc J. I. Zimmermann
- Department of Pediatrics, Research School Oncology and Developmental Biology-grow, Maastricht University Medical Hospital, Maastricht, The Netherlands
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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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