Continuous positive airway pressure titration in infants with severe upper airway obstruction or bronchopulmonary dysplasia

Critical Care

Brigitte Fauroux¹  Arnaud Picard⁴  Nicolas Leboulanger¹  Sabrina Aloui²  Adriana Ramirez³  Sonia Khirani² 

[1] INSERM U 955, Créteil, France;AP-HP, Hôpital Armand Trousseau, Pediatric Pulmonary Department, Paris, France;ADEP Assistance, Suresnes, France;AP-HP, Hôpital Armand Trousseau, Pediatric Plastic Surgery and Maxillofacial Department, Paris, France

关键词: Infant;    Expiratory abdominal activity;    Oesophageal pressure;    Continuous positive airway pressure;    Airway obstruction;   

Others  :  817947
DOI  :  10.1186/cc12846

 received in 2013-03-27, accepted in 2013-07-26,  发布年份 2013

【 摘 要 】

a

Introduction

Noninvasive continuous positive airway pressure (CPAP) is recognized as an effective treatment for severe airway obstruction in young children. The aim of the present study was to compare a clinical setting with a physiological setting of noninvasive CPAP in infants with nocturnal alveolar hypoventilation due to severe upper airway obstruction (UAO) or bronchopulmonary dysplasia (BPD).

Methods

The breathing pattern and respiratory muscle output of all consecutive infants due to start CPAP in our noninvasive ventilation unit were retrospectively analysed. CPAP set on clinical noninvasive parameters (clinical CPAP) was compared to CPAP set on the normalization or the maximal reduction of the oesophageal pressure (Poes) and transdiaphragmatic pressure (Pdi) swings (physiological CPAP). Expiratory gastric pressure (Pgas) swing was measured.

Results

The data of 12 infants (mean age 10 ± 8 mo) with UAO (n = 7) or BPD (n = 5) were gathered. The mean clinical CPAP (8 ± 2 cmH₂O) was associated with a significant decrease in Poes and Pdi swings. Indeed, Poes swing decreased from 31 ± 15 cmH₂O during spontaneous breathing to 21 ± 10 cmH₂O during CPAP (P < 0.05). The mean physiological CPAP level was 2 ± 2 cmH₂O higher than the mean clinical CPAP level and was associated with a significantly greater improvement in all indices of respiratory effort (Poes swing 11 ± 5 cm H₂O; P < 0.05 compared to clinical CPAP). Expiratory abdominal activity was present during the clinical CPAP and decreased during physiological CPAP.

Conclusions

A physiological setting of noninvasive CPAP, based on the recording of Poes and Pgas, is superior to a clinical setting, based on clinical noninvasive parameters. Expiratory abdominal activity was present during spontaneous breathing and decreased in the physiological CPAP setting.

【 授权许可】

   
2013 Fauroux et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

Figure 3.

Figure 4.

【 参考文献 】

• [1]Guilleminault C, Nino-Murcia G, Heldt G, Baldwin R, Hutchinson D: Alternative treatment to tracheostomy in obstructive sleep apnea syndrome: nasal continuous positive airway pressure in young children. Pediatrics 1986, 78:797-802.
• [2]Guilleminault C, Pelayo R, Clerk A, Leger D, Bocian RC: Home nasal continuous positive airway pressure in infants with sleep-disordered breathing. J Pediatr 1995, 127:905-912.
• [3]Fauroux B, Pigeot J, Polkey MI, Roger G, Boulé M, Clément A, Lofaso F: Chronic stridor caused by laryngomalacia in children: work of breathing and effects of noninvasive ventilatory assistance. Am J Respir Crit Care Med 2001, 164:1874-1878.
• [4]Waters WA, Everett FM, Bruderer JW, Sullivan CE: Obstructive sleep apnea: the use of nasal CPAP in 80 children. Am J Respir Crit Care Med 1995, 152:780-785.
• [5]Essouri S, Nicot F, Clément A, Garabedian EN, Roger G, Lofaso F, Fauroux B: Noninvasive positive pressure ventilation in infants with upper airway obstruction: comparison of continuous and bilevel positive pressure. Intensive Care Med 2005, 31:574-580.
• [6]Leboulanger N, Picard A, Soupre V, Aubertin G, Denoyelle F, Galliani E, Roger G, Garabedian EN, Fauroux B: Physiological and clinical benefits of noninvasive respiratory support in infants with Pierre Robin sequence. Pediatrics 2010, 126:e1056-e1063.
• [7]Iber C, Ancoli-Israel S, Chesson AL Jr, Quan SF: for the American Academy of Sleep Medicine. In AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications. Westchester, IL: American Academy of Sleep Medicine; 2007.
• [8]Kushida CA, Chediak A, Berry RB, Brown LK, Gozal D, Iber C, Parthasarathy S, Quan SF, Rowley JA: Positive Airway Pressure Titration Task Force of the American Academy of Sleep Medicine: Clinical guidelines for the manual titration of positive airway pressure in patients with obstructive sleep apnea. J Clin Sleep Med 2008, 4:157-171.
• [9]Essouri S, Durand P, Chevret L, Balu L, Devictor D, Fauroux B, Tissières P: Optimal level of nasal continuous positive airway pressure in severe viral bronchiolitis. Intensive Care Med 2011, 37:2002-2007.
• [10]Fauroux B, Lavis JF, Nicot F, Picard A, Boelle PY, Clément A, Vazquez MP: Facial side effects during noninvasive positive pressure ventilation in children. Intensive Care Med 2005, 31:965-969.
• [11]Ramirez A, Delord V, Khirani S, Leroux K, Cassier S, Kadlub N, Aubertin A, Picard A, Fauroux B: Interfaces for long term noninvasive positive pressure ventilation in children. Intensive Care Med 2012, 38:655-662.
• [12]Fauroux B, Pigeot J, Polkey MI, Isabey D, Clément A, Lofaso F: In vivo physiological comparison of two ventilators used for domiciliary ventilation in children with cystic fibrosis. Crit Care Med 2001, 29:2097-2105.
• [13]Stell IM, Tompkins S, Lovell AT, Goldstone JC, Moxham J: An in vivo comparison of a catheter mounted pressure transducer system with conventional balloon catheters. Eur Respir J 1999, 13:1158-1163.
• [14]Baydur A, Behrakis PK, Zin WA, Jaeger MJ, Milic-Emili JA: A simple method for assessing the validity of the esophageal balloon technique. Am Rev Respir Dis 1982, 126:788-791.
• [15]Sassoon CSH, Light RW, Lodia R, Sieck GC, Mahutte CK: Pressure-time product during continuous positive airway pressure, pressure support ventilation and T-piece during weaning from mechanical ventilation. Am Rev Respir Dis 1991, 143:459-475.
• [16]Field S, Grassino A, Sanci S: Respiratory muscle oxygen consumption estimated by the diaphragm pressure-time index. J Appl Physiol 1984, 57:44-51.
• [17]Barnard PA, Levine S: Critique on application of diaphragmatic time-tension index to spontaneously breathing humans. J Appl Physiol 1986, 60:1067-1072.
• [18]Parthasarathy S, Jubran A, Tobin MJ: Assessment of neural inspiratory time in ventilator-supported patients. Am J Respir Crit Care Med 2000, 162:546-552.
• [19]Lofaso F, d'Ortho M, Fodil F, Delclaux C, Harf A, Lorino A: Abdominal muscle activity in sleep apnea during continuous positive airway pressure titration. Chest 2001, 120:390-396.
• [20]Campbell EJM, Green JH: The variations in intra-abdominal pressure and the activity of the abdominal muscles during breathing; a study in men. J Physiol 1953, 122:282-290.
• [21]Tiddens HA, Hofhuis W, Casotti V, Hop WC, Hulsmann AR, de Jongste JC: Airway dimensions in bronchopulmonary dysplasia: implications for airflow obstruction. Pediatr Pulmonol 2008, 43:1206-1213.
• [22]Hilgendorff A, Reiss I, Gortner L, Schüler D, Weber K, Lindemann H: Impact of airway obstruction on lung function in very preterm infants at term. Pediatr Crit Care Med 2008, 9:629-635.
• [23]Giovannini-Chami L, Khirani S, Thouvenin G, Ramirez A, Fauroux B: Work of breathing to optimize noninvasive ventilation in bronchiolitis obliterans. Intensive Care Med 2012, 38:722-724.
• [24]Agostoni E: Diaphragm activity and thoracoabdominal mechanics during positive pressure breathing. J Appl Physiol 1962, 17:215-220.
• [25]Alex CG, Aronson RM, Onal E, Lopata M: Effects of continuous positive airway pressure on upper airway and respiratory muscle activity. J Appl Physiol 1987, 62:2026-2030.
• [26]Layon J, Banner MJ, Jaeger MJ, Peterson CV, Gallagher TJ, Modell JH: Continuous positive airway pressure and expiratory positive airway pressure increase functional residual capacity equivalently. Chest 1986, 89:517-521.
• [27]Seo WH, Guilleminault C: Periodic leg movement, nasal CPAP, and expiratory muscles. Chest 2012, 142:111-118.
• [28]Sforza E, Nicolas A, Lavigne G, Gosselin A, Petit D, Montplaisir J: EEG and cardiac activation during periodic leg movements in sleep: support for a hierarchy of arousal responses. Neurology 1999, 52:786-791.