Autotitrating external positive end-expiratory airway pressure to abolish expiratory flow limitation during tidal breathing in patients with severe COPD: a physiological study

Eui Sik Suh; Pasquale Pompilio; Swapna Mandal; Peter Hill; Georgios Kaltsakas; Patrick B. Murphy; Robert Romano; John Moxham; Raffaele Dellaca; Nicholas Hart

doi:10.1183/13993003.02234-2019

Autotitrating external positive end-expiratory airway pressure to abolish expiratory flow limitation during tidal breathing in patients with severe COPD: a physiological study

Eui Sik Suh, Pasquale Pompilio, Swapna Mandal, Peter Hill, Georgios Kaltsakas, Patrick B. Murphy, Robert Romano, John Moxham, Raffaele Dellaca, Nicholas Hart

Research output: Contribution to journal › Article › peer-review

15 Citations (Scopus)

Abstract

Background: The optimal noninvasive application of external positive end-expiratory pressure (EPAP) to abolish tidal-breathing expiratory flow limitation (EFL _T) and minimise intrinsic positive end-expiratory pressure (PEEP _i) is challenging in COPD patients. We investigated whether auto-titrating EPAP, using the forced oscillation technique (FOT) to detect and abolish EFL _T, would minimise PEEP _i, work of breathing and neural respiratory drive (NRD) in patients with severe COPD. Methods: Patients with COPD with chronic respiratory failure underwent auto-titration of EPAP using a FOT-based algorithm that detected EFL _T. Once optimal EPAP was identified, manual titration was performed to assess NRD (using diaphragm and parasternal intercostal muscle electromyography, EMG _di and EMG _para, respectively), transdiaphragmatic inspiratory pressure swings (ΔP _di), transdiaphragmatic pressure–time product (PTP _di) and PEEP _i, between EPAP levels 2 cmH ₂O below to 3 cmH ₂O above optimal EPAP. Results: Of 10 patients enrolled (age 65±6 years; male 60%; body mass index 27.6±7.2 kg.m ⁻²; forced expiratory volume in 1 s 28.4±8.3% predicted), eight had EFL _T, and optimal EPAP was 9 (range 4–13) cmH ₂O. NRD was reduced from baseline EPAP at 1 cmH ₂O below optimal EPAP on EMG _di and at optimal EPAP on EMG _para. In addition, at optimal EPAP, PEEP _i (0.80±1.27 cmH ₂O versus 1.95± 1.70 cmH ₂O; p<0.05) was reduced compared with baseline. PTP _di (10.3±7.8 cmH ₂O·s ⁻¹ versus 16.8±8.8 cmH ₂O·s ⁻¹; p<0.05) and ΔP _di (12.4±7.8 cmH ₂O versus 18.2±5.1 cmH ₂O; p<0.05) were reduced at optimal EPAP+1 cmH ₂O compared with baseline. Conclusion: Autotitration of EPAP, using a FOT-based algorithm to abolish EFL _T, minimises transdiaphragmatic pressure swings and NRD in patients with COPD and chronic respiratory failure.

Original language	English
Article number	1902234
Journal	The European respiratory journal
Volume	56
Issue number	3
DOIs	https://doi.org/10.1183/13993003.02234-2019
Publication status	Published - 1 Sept 2020

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10.1183/13993003.02234-2019

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Suh, E. S., Pompilio, P., Mandal, S., Hill, P., Kaltsakas, G., Murphy, P. B., Romano, R., Moxham, J., Dellaca, R., & Hart, N. (2020). Autotitrating external positive end-expiratory airway pressure to abolish expiratory flow limitation during tidal breathing in patients with severe COPD: a physiological study. The European respiratory journal, 56(3), Article 1902234. https://doi.org/10.1183/13993003.02234-2019

@article{84f002be182e45829502eafa969282e0,

title = "Autotitrating external positive end-expiratory airway pressure to abolish expiratory flow limitation during tidal breathing in patients with severe COPD: a physiological study",

abstract = "Background: The optimal noninvasive application of external positive end-expiratory pressure (EPAP) to abolish tidal-breathing expiratory flow limitation (EFL T) and minimise intrinsic positive end-expiratory pressure (PEEP i) is challenging in COPD patients. We investigated whether auto-titrating EPAP, using the forced oscillation technique (FOT) to detect and abolish EFL T, would minimise PEEP i, work of breathing and neural respiratory drive (NRD) in patients with severe COPD. Methods: Patients with COPD with chronic respiratory failure underwent auto-titration of EPAP using a FOT-based algorithm that detected EFL T. Once optimal EPAP was identified, manual titration was performed to assess NRD (using diaphragm and parasternal intercostal muscle electromyography, EMG di and EMG para, respectively), transdiaphragmatic inspiratory pressure swings (ΔP di), transdiaphragmatic pressure–time product (PTP di) and PEEP i, between EPAP levels 2 cmH 2O below to 3 cmH 2O above optimal EPAP. Results: Of 10 patients enrolled (age 65±6 years; male 60%; body mass index 27.6±7.2 kg.m −2; forced expiratory volume in 1 s 28.4±8.3% predicted), eight had EFL T, and optimal EPAP was 9 (range 4–13) cmH 2O. NRD was reduced from baseline EPAP at 1 cmH 2O below optimal EPAP on EMG di and at optimal EPAP on EMG para. In addition, at optimal EPAP, PEEP i (0.80±1.27 cmH 2O versus 1.95± 1.70 cmH 2O; p<0.05) was reduced compared with baseline. PTP di (10.3±7.8 cmH 2O·s −1 versus 16.8±8.8 cmH 2O·s −1; p<0.05) and ΔP di (12.4±7.8 cmH 2O versus 18.2±5.1 cmH 2O; p<0.05) were reduced at optimal EPAP+1 cmH 2O compared with baseline. Conclusion: Autotitration of EPAP, using a FOT-based algorithm to abolish EFL T, minimises transdiaphragmatic pressure swings and NRD in patients with COPD and chronic respiratory failure. ",

author = "Suh, {Eui Sik} and Pasquale Pompilio and Swapna Mandal and Peter Hill and Georgios Kaltsakas and Murphy, {Patrick B.} and Robert Romano and John Moxham and Raffaele Dellaca and Nicholas Hart",

year = "2020",

month = sep,

day = "1",

doi = "10.1183/13993003.02234-2019",

language = "English",

volume = "56",

journal = "The European respiratory journal",

issn = "1399-3003",

publisher = "European Respiratory Society",

number = "3",

}

Suh, ES, Pompilio, P, Mandal, S, Hill, P, Kaltsakas, G , Murphy, PB, Romano, R, Moxham, J, Dellaca, R & Hart, N 2020, 'Autotitrating external positive end-expiratory airway pressure to abolish expiratory flow limitation during tidal breathing in patients with severe COPD: a physiological study', The European respiratory journal, vol. 56, no. 3, 1902234. https://doi.org/10.1183/13993003.02234-2019

Autotitrating external positive end-expiratory airway pressure to abolish expiratory flow limitation during tidal breathing in patients with severe COPD: a physiological study. / Suh, Eui Sik; Pompilio, Pasquale; Mandal, Swapna et al.
In: The European respiratory journal, Vol. 56, No. 3, 1902234, 01.09.2020.

Research output: Contribution to journal › Article › peer-review

TY - JOUR

T1 - Autotitrating external positive end-expiratory airway pressure to abolish expiratory flow limitation during tidal breathing in patients with severe COPD

T2 - a physiological study

AU - Suh, Eui Sik

AU - Pompilio, Pasquale

AU - Mandal, Swapna

AU - Hill, Peter

AU - Kaltsakas, Georgios

AU - Murphy, Patrick B.

AU - Romano, Robert

AU - Moxham, John

AU - Dellaca, Raffaele

AU - Hart, Nicholas

PY - 2020/9/1

Y1 - 2020/9/1

N2 - Background: The optimal noninvasive application of external positive end-expiratory pressure (EPAP) to abolish tidal-breathing expiratory flow limitation (EFL T) and minimise intrinsic positive end-expiratory pressure (PEEP i) is challenging in COPD patients. We investigated whether auto-titrating EPAP, using the forced oscillation technique (FOT) to detect and abolish EFL T, would minimise PEEP i, work of breathing and neural respiratory drive (NRD) in patients with severe COPD. Methods: Patients with COPD with chronic respiratory failure underwent auto-titration of EPAP using a FOT-based algorithm that detected EFL T. Once optimal EPAP was identified, manual titration was performed to assess NRD (using diaphragm and parasternal intercostal muscle electromyography, EMG di and EMG para, respectively), transdiaphragmatic inspiratory pressure swings (ΔP di), transdiaphragmatic pressure–time product (PTP di) and PEEP i, between EPAP levels 2 cmH 2O below to 3 cmH 2O above optimal EPAP. Results: Of 10 patients enrolled (age 65±6 years; male 60%; body mass index 27.6±7.2 kg.m −2; forced expiratory volume in 1 s 28.4±8.3% predicted), eight had EFL T, and optimal EPAP was 9 (range 4–13) cmH 2O. NRD was reduced from baseline EPAP at 1 cmH 2O below optimal EPAP on EMG di and at optimal EPAP on EMG para. In addition, at optimal EPAP, PEEP i (0.80±1.27 cmH 2O versus 1.95± 1.70 cmH 2O; p<0.05) was reduced compared with baseline. PTP di (10.3±7.8 cmH 2O·s −1 versus 16.8±8.8 cmH 2O·s −1; p<0.05) and ΔP di (12.4±7.8 cmH 2O versus 18.2±5.1 cmH 2O; p<0.05) were reduced at optimal EPAP+1 cmH 2O compared with baseline. Conclusion: Autotitration of EPAP, using a FOT-based algorithm to abolish EFL T, minimises transdiaphragmatic pressure swings and NRD in patients with COPD and chronic respiratory failure.

AB - Background: The optimal noninvasive application of external positive end-expiratory pressure (EPAP) to abolish tidal-breathing expiratory flow limitation (EFL T) and minimise intrinsic positive end-expiratory pressure (PEEP i) is challenging in COPD patients. We investigated whether auto-titrating EPAP, using the forced oscillation technique (FOT) to detect and abolish EFL T, would minimise PEEP i, work of breathing and neural respiratory drive (NRD) in patients with severe COPD. Methods: Patients with COPD with chronic respiratory failure underwent auto-titration of EPAP using a FOT-based algorithm that detected EFL T. Once optimal EPAP was identified, manual titration was performed to assess NRD (using diaphragm and parasternal intercostal muscle electromyography, EMG di and EMG para, respectively), transdiaphragmatic inspiratory pressure swings (ΔP di), transdiaphragmatic pressure–time product (PTP di) and PEEP i, between EPAP levels 2 cmH 2O below to 3 cmH 2O above optimal EPAP. Results: Of 10 patients enrolled (age 65±6 years; male 60%; body mass index 27.6±7.2 kg.m −2; forced expiratory volume in 1 s 28.4±8.3% predicted), eight had EFL T, and optimal EPAP was 9 (range 4–13) cmH 2O. NRD was reduced from baseline EPAP at 1 cmH 2O below optimal EPAP on EMG di and at optimal EPAP on EMG para. In addition, at optimal EPAP, PEEP i (0.80±1.27 cmH 2O versus 1.95± 1.70 cmH 2O; p<0.05) was reduced compared with baseline. PTP di (10.3±7.8 cmH 2O·s −1 versus 16.8±8.8 cmH 2O·s −1; p<0.05) and ΔP di (12.4±7.8 cmH 2O versus 18.2±5.1 cmH 2O; p<0.05) were reduced at optimal EPAP+1 cmH 2O compared with baseline. Conclusion: Autotitration of EPAP, using a FOT-based algorithm to abolish EFL T, minimises transdiaphragmatic pressure swings and NRD in patients with COPD and chronic respiratory failure.

UR - http://www.scopus.com/inward/record.url?scp=85090816304&partnerID=8YFLogxK

U2 - 10.1183/13993003.02234-2019

DO - 10.1183/13993003.02234-2019

M3 - Article

C2 - 32444404

AN - SCOPUS:85090816304

SN - 1399-3003

VL - 56

JO - The European respiratory journal

JF - The European respiratory journal

IS - 3

M1 - 1902234

ER -

Autotitrating external positive end-expiratory airway pressure to abolish expiratory flow limitation during tidal breathing in patients with severe COPD: a physiological study

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