Tidal volume and airway pressure under percutaneous transtracheal ventilation without a jet ventilator: comparison of high-flow oxygen ventilation and manual ventilation in complete and incomplete upper airway obstruction models

Abstract Introduction Positive airway pressure-induced upper airway obstruction has been reported with the treatment of obstructive sleep apnea (OSA) using continuous positive airway pressure (CPAP) along with an oronasal interface. Here we describe a case of persistent treatment emergent central sleep apnea (TECSA) inadequately treated with adaptive servo ventilation (ASV), with an airflow pattern suggestive of ASV-induced upper airway obstruction. Report of Case A 32-year-old male, with severe OSA (apnea hypopnea index: 52.4) and no other significant past medical history, was treated with CPAP and required higher pressures during titration sleep studies to alleviate obstructive events, despite a Mallampati Class II airway and a normal body mass index. Drug-Induced Sleep Endoscopy (DISE) showed a complete velopharynx and oropharynx anterior posterior (AP) collapse, long soft palate, which improved with neck extension. CPAP therapy, however, did not result in any symptomatic benefit and compliance reports revealed high residual AHI and persistent TECSA. He underwent an ASV titration sleep study up to a final setting of expiratory positive airway pressure 9 cm H2O, pressure support 6-15 cm H2O (auto-rate), with a full-face mask due to high oral leak associated with the nasal interface. The ASV device detected central apneas and provided mandatory breaths, but did not capture the thorax or abdomen, despite normal mask pressure tracings. Several such apneas occurred, with significant oxyhemoglobin desaturation. Conclusion We postulate that the ASV failure to correct central sleep apnea as evidenced by the absence of thoracoabdominal inspiratory effort, occurred due to ASV-induced upper airway obstruction. Further treatment options for this ASV phenomenon are to pursue an ASV-assisted DISE and determine the effectiveness of adjunctive therapy including neck extension, nasal mask with a mouth closing device and a mandibular assist device.

Download Full-text

Needle Tracheostomy: A Laboratory Study

Anaesthesia and Intensive Care ◽

10.1177/0310057x8000800112 ◽

1980 ◽

Vol 8 (1) ◽

pp. 72-80 ◽

Cited By ~ 2

Author(s):

T. L. Dobbinson ◽

J. Whalen ◽

D. A. Pelton ◽

H. I. A. Nisbet ◽

G. Volgyesi

Keyword(s):

Airway Obstruction ◽

Laboratory Study ◽

Artificial Ventilation ◽

Flow Characteristics ◽

Upper Airway ◽

Upper Airway Obstruction ◽

Spontaneous Respiration ◽

Pressure Flow ◽

Transtracheal Ventilation ◽

Tracheal Occlusion

Percutaneous needle tracheostomy and transtracheal ventilation continues to be advocated for the management of upper airway obstruction. Recent studies recommend the use of artificial ventilation. However, as apparatus for this is not always available and because there remains some doubt regarding conditions for successful use of needle tracheostomy during spontaneous respiration, we undertook such a study in dogs. Pressure-flow characteristics of short hollow needles 18–10 SWG were first determined. The smallest of these (14 SWG Bardic Intracath) that would deliver flow sufficient (by calculation) to meet the respiratory requirement of 10–13 kg laboratory dogs was selected for further study. Respiration was possible by spontaneous or artificial methods in the presence of complete tracheal occlusion. Little or no deterioration was noted in an hour of such breathing. Artificial ventilation by machine and by hand could considerably lower PaCO2. We conclude that the technique is possible provided appropriate needles are selected and care is given to their method of use.

Download Full-text

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

Critical Care ◽

10.1186/cc12846 ◽

2013 ◽

Vol 17 (4) ◽

pp. R167 ◽

Cited By ~ 22

Author(s):

Sonia Khirani ◽

Adriana Ramirez ◽

Sabrina Aloui ◽

Nicolas Leboulanger ◽

Arnaud Picard ◽

...

Keyword(s):

Continuous Positive Airway Pressure ◽

Airway Obstruction ◽

Bronchopulmonary Dysplasia ◽

Airway Pressure ◽

Positive Airway Pressure ◽

Upper Airway ◽

Upper Airway Obstruction

Download Full-text

Effects of continuous positive airway pressure and helium inhalation on thoracoabdominal asynchrony in an infant with post-extubation upper airway obstruction

Pediatric Anesthesia ◽

10.1111/j.1460-9592.2008.02460.x ◽

2008 ◽

Vol 18 (5) ◽

pp. 451-452 ◽

Cited By ~ 1

Author(s):

Yumiko Mizuno ◽

Hideaki Imanaka ◽

Muneyuki Takeuchi

Keyword(s):

Continuous Positive Airway Pressure ◽

Airway Obstruction ◽

Airway Pressure ◽

Positive Airway Pressure ◽

Upper Airway ◽

Upper Airway Obstruction ◽

Thoracoabdominal Asynchrony

Download Full-text

Transtracheal ventilation at different degrees of upper airway obstruction evaluated with a mechanical lung model

European Journal of Anaesthesiology ◽

10.1097/00003643-200505001-00234 ◽

2005 ◽

Vol 22 (Supplement 34) ◽

pp. 66-67

Author(s):

M. A. Staber ◽

J. Henderson

Keyword(s):

Airway Obstruction ◽

Upper Airway ◽

Upper Airway Obstruction ◽

Lung Model ◽

Transtracheal Ventilation ◽

Mechanical Lung

Download Full-text

Surgical Versus Nonsurgical Interventions to Relieve upper Airway Obstruction in Children with Pierre Robin Sequence

Canadian Respiratory Journal ◽

10.1155/2015/798076 ◽

2015 ◽

Vol 22 (3) ◽

pp. 171-175 ◽

Cited By ~ 10

Author(s):

Karen Kam ◽

Meghan McKay ◽

Joanna MacLean ◽

Manisha B Witmans ◽

Sheldon Spier ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Birth Weight ◽

Airway Obstruction ◽

Airway Pressure ◽

Positive Airway Pressure ◽

Upper Airway ◽

Upper Airway Obstruction ◽

Pierre Robin Sequence ◽

Pierre Robin

BACKGROUND: Newborns with Pierre Robin sequence (PRS) often experience chronic intermittent hypoxemia/hypoventilation associated with airway obstruction. The heterogeneity of the severity of upper airway obstruction makes management a challenge; the optimal intervention in individual cases is not clear.OBJECTIVE: To investigate the prevalence of surgical/nonsurgical interventions for PRS at two children’s hospitals. Patient characteristics and outcomes were examined.METHODS: The present retrospective chart review identified 139 patients with PRS born between 2000 and 2010. Demographic information, mode of airway management, associated anomalies and syndromes, polysomnography results, length of intensive care unit and hospital stay, complications and deaths were extracted.RESULTS: Interventions included prone positioning (alone [61%]), tongue-lip adhesion (45%), nasopharyngeal intubation (28%), continuous positive airway pressure (20%), tracheostomy (19%) and mandibular distraction osteogenesis (5%). Tracheostomies were more prevalent in syndromic patients (P=0.03). Patients who underwent tracheostomy had a lower birth weight (P=0.03) compared with newborns with other interventions. Patients who underwent surgical interventions had longer intensive care unit stays (P<0.001). No intervention was associated with a statistically significant likelihood of requiring a subsequent intervention. Thirty percent of patients underwent polysomnography, with a higher proportion of these using continuous positive airway pressure (n=15) (P<0.01).CONCLUSIONS: In the present descriptive study, patients with syndromic PRS or low birth weight underwent early intervention, which included a tracheostomy. Objective measures of airway obstruction were underutilized. Decision making regarding evaluation and management of upper airway obstruction in this population remains clinician and resource dependent. Reporting data obtained from a large cohort of PRS patients is important to compare experiences and motivate future studies investigating this complex condition.

Download Full-text

Repeatability of sites of sleep-induced upper airway obstruction. A 2-night study based on recordings of airway pressure and flow

European Archives of Oto-Rhino-Laryngology ◽

10.1007/s004050100330 ◽

2001 ◽

Vol 258 (5) ◽

pp. 259-264 ◽

Cited By ~ 17

Author(s):

Jan Rollheim ◽

Magne Tvinnereim ◽

Jan Sitek ◽

Terje Osnes

Keyword(s):

Airway Obstruction ◽

Airway Pressure ◽

Upper Airway ◽

Upper Airway Obstruction

Download Full-text

Tracheomalacia in an Infant with Multiplex Congenita (Larsen's) Syndrome

Annals of Otology Rhinology & Laryngology ◽

10.1177/000348948109000401 ◽

1981 ◽

Vol 90 (4) ◽

pp. 303-306 ◽

Cited By ~ 13

Author(s):

Kenneth M. Grundfast ◽

Robert Kanter ◽

Anwar Mumtaz ◽

Murray Pollack

Keyword(s):

Continuous Positive Airway Pressure ◽

Respiratory Distress ◽

Airway Obstruction ◽

Airway Pressure ◽

Positive Airway Pressure ◽

Upper Airway ◽

Upper Airway Obstruction ◽

Tracheal Lumen ◽

Thoracic Cage ◽

Adequate Ventilation

An infant born with multiplex congenita (Larsen's) syndrome developed respiratory distress 30 days following tracheostomy for relief of upper airway obstruction. The infant had structural and functional abnormalities of the thoracic cage. Tracheobronchoscopy revealed excessive compliance of the trachea with a tendency for collapse of the tracheal rings and obliteration of the tracheal lumen. Continuous positive airway pressure in the range of 20–25 cm H2O was used to maintain patency of the tracheal lumen and assure adequate ventilation. Hemodynamic and pulmonary barometric complications often observed when high levels of positive airway pressure are utilized in infants were not observed.

Download Full-text