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. 2020 Sep 10;56(3):1902234.
doi: 10.1183/13993003.02234-2019. Print 2020 Sep.

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  1   2 , Pasquale Pompilio  3 , Swapna Mandal  1   4 , Peter Hill  5 , Georgios Kaltsakas  1   4 , Patrick B Murphy  1   4 , Robert Romano  5 , John Moxham  4 , Raffaele Dellaca  3 , Nicholas Hart  1   4
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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 et al. Eur Respir J. .
Free article

Abstract

Background: The optimal noninvasive application of external positive end-expiratory pressure (EPAP) to abolish tidal-breathing expiratory flow limitation (EFLT) and minimise intrinsic positive end-expiratory pressure (PEEPi) is challenging in COPD patients. We investigated whether auto-titrating EPAP, using the forced oscillation technique (FOT) to detect and abolish EFLT, would minimise PEEPi, 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 EFLT. Once optimal EPAP was identified, manual titration was performed to assess NRD (using diaphragm and parasternal intercostal muscle electromyography, EMGdi and EMGpara, respectively), transdiaphragmatic inspiratory pressure swings (ΔP di), transdiaphragmatic pressure-time product (PTPdi) and PEEPi, between EPAP levels 2 cmH2O below to 3 cmH2O 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 EFLT, and optimal EPAP was 9 (range 4-13) cmH2O. NRD was reduced from baseline EPAP at 1 cmH2O below optimal EPAP on EMGdi and at optimal EPAP on EMGpara. In addition, at optimal EPAP, PEEPi (0.80±1.27 cmH2O versus 1.95± 1.70 cmH2O; p<0.05) was reduced compared with baseline. PTPdi (10.3±7.8 cmH2O·s-1 versus 16.8±8.8 cmH2O·s-1; p<0.05) and ΔP di (12.4±7.8 cmH2O versus 18.2±5.1 cmH2O; p<0.05) were reduced at optimal EPAP+1 cmH2O compared with baseline.

Conclusion: Autotitration of EPAP, using a FOT-based algorithm to abolish EFLT, minimises transdiaphragmatic pressure swings and NRD in patients with COPD and chronic respiratory failure.

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Conflict of interest statement

Conflict of interest: E-S. Suh reports grants and personal fees for educational work from Philips Respironics, grants from Philips Research, during the conduct of the study. Conflict of interest: P. Pompilio is one of the founders of RESTECH srl, company that designs, manufactures and sells devices for lung function testing based on the forced oscillation technique. Conflict of interest: S. Mandal reports personal fees for consultancy and educational work from Philips, outside the submitted work. Conflict of interest: P. Hill is an employee of Philips. Conflict of interest: G. Kaltsakas has nothing to disclose. Conflict of interest: P.B. Murphy reports receiving reimbursement for expenses for travel to conferences and lecture fees from Philips Respironics, ResMed, Fisher & Paykel, and B&D Electromedical. Conflict of interest: R. Romano is an employee of Philips. Conflict of interest: J. Moxham has nothing to disclose. Conflict of interest: R. Dellaca reports grants from Acutronic, outside the submitted work; has a patent on the detection of EFL by FOT with royalties paid to Philips Respironics and Restech srl, a patent on monitoring lung volume recruitment by FOT with royalties paid to Vyaire, and a patent on early detection of exacerbations by home monitoring of FOT with royalties paid to Restech; and is co-founder and shareholder of Restech srl, a spin-off company of the Politecnico di Milano University producing medical devices for lung function testing based on FOT. Conflict of interest: N. Hart reports personal fees from Fisher & Paykel, grants from Philips Respironics, ResMed and B&D Electromedical, during the conduct of the study; and has a patent pending on the Myotrace technology.

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