ID: 127: DECREASED CPAP ADHERENCE IN NON-OBESE OSA PATIENTS WITH REVERSIBLE UPPER AIRWAY OBSTRUCTION

2016 ◽  
Vol 64 (4) ◽  
pp. 970.1-970
Author(s):  
J Doumit ◽  
P Belvitch ◽  
I Rubinstein
Keyword(s):  
Airway Obstruction ◽  
Airway Resistance ◽  
Upper Airway ◽  
Upper Airway Obstruction ◽  
Beta Agonist ◽  
Upper Airways ◽  
Short Acting ◽  
Cpap Adherence ◽  
Upper Airway Resistance ◽  
Airways Obstruction

RationaleUpper airway resistance is critical to the pathophysiology of obstructive sleep apnea (OSA). We have previously characterized a subset of patients with OSA who have evidence of reversible upper airways resistance as measured by spirometry. Specifically, these patients have an increased FEF50/FIF50 ratio which decreases with administration of a short acting bronchodilator. On average these patients had a lower BMI (average 27) compared to OSA patients as a whole suggesting the possibility of unique upper airway pathophysiology among this group. In the current study, we identify additional patients with OSA who have reversible upper airways obstruction on spirometry and characterize their compliance with CPAP therapy as compared to a traditional OSA population.MethodsWe retrospectively evaluated patients who had a sleep screen suggestive of OSA in the last 2 years. Patients who also had spirometry in the previous 5 years were identified for further analysis. Those patients with either normal spirometry or fixed obstructive defects who had a decrease in the FEF50/FIF50 ratio after administration of a short acting inhaled beta agonist (albuterol) were then characterized. We then measured objective CPAP adherence using data downloaded from the positive airway pressure device with adherence defined as CPAP use >4 hrs more than 70% of nights over a 30 day period.ResultsWe identified 70 patients with positive sleep screens who also had spirometry demonstrating normal of fixed lower expiratory obstruction with evidence of upper airways obstruction as demonstrated by a decreased FEF50/FIF50 ratio. Of these, 45 had a decrease in the FEF50/FIF50 ratio of more than 20% following administration of inhaled albuterol. Overall, CPAP adherence between those with reversible upper airways obstruction and those without was similar (23/45=51% vs 14/26=54%). However, subgroup analysis revealed a lower adherence rate among non-obese patients (BMI<30) with reversible airways obstruction (6/16=36%).ConclusionThe identification of a subset of patients with OSA who have evidence of decreased upper airway resistance in response to inhaled bronchodilator suggests unique pathology in this group. Decreased adherence to traditional OSA therapy with CPAP among these patients is additional evidence of differential pathophysiology requiring novel treatments. Specifically, treatment with a long acting beta agonist (LABA) prior to sleep may reduce upper airway obstruction and be better tolerated than CPAP.

Motor responses to positive-pressure breathing in the developing opossum

1985 ◽  
Vol 58 (5) ◽  
pp. 1489-1495 ◽  
Author(s):  
J. P. Farber
Keyword(s):  
Airway Resistance ◽  
Upper Airway ◽  
Abdominal Muscle ◽  
Positive Pressure ◽  
Postnatal Life ◽  
Abdominal Muscles ◽  
Upper Airways ◽  
Motor Responses ◽  
Upper Airway Resistance ◽  
Upper Airway Muscles

The suckling opossum exhibits an expiration-phased discharge in abdominal muscles during positive-pressure breathing (PPB); the response becomes apparent, however, only after the 3rd-5th wk of postnatal life. The purpose of this study was to determine whether the early lack of activation represented a deficiency of segmental outflow to abdominal muscles or whether comparable effects were observed in cranial outflows to muscles of the upper airways due to immaturity of afferent and/or supraspinal pathways. Anesthetized suckling opossums between 15 and 50 days of age were exposed to PPB; electromyogram (EMG) responses in diaphragm and abdominal muscles were measured, along with EMG of larynx dilator muscles and/or upper airway resistance. In animals older than approximately 30 days of age, the onset of PPB was associated with a prolonged expiration-phased EMG activation of larynx dilator muscles and/or decreased upper airway resistance, along with expiratory recruitment of the abdominal muscle EMG. These effects persisted as long as the load was maintained. Younger animals showed only those responses related to the upper airway; in fact, activation of upper airway muscles during PPB could be associated with suppression of the abdominal motor outflow. After unilateral vagotomy, abdominal and upper airway motor responses to PPB were reduced. The balance between PPB-induced excitatory and inhibitory or disfacilitory influences from the supraspinal level on abdominal motoneurons and/or spinal processing of information from higher centers may shift toward net excitation as the opossum matures.

Mouth and nose resistance in newborn kittens and puppies

1981 ◽  
Vol 51 (3) ◽  
pp. 641-645 ◽  
Author(s):  
J. P. Mortola ◽  
J. T. Fisher
Keyword(s):  
Mechanical Properties ◽  
Airway Obstruction ◽  
Flow Rate ◽  
Muscle Tone ◽  
Upper Airway ◽  
Upper Airway Obstruction ◽  
Upper Airways ◽  
Airway Patency ◽  
The Difference ◽  
Adult Cats

Newborn mammals, including infants, have difficulties in mouth breathing when the nasal passages are occluded. In this study we examined the possibility that differences in the passive mechanical properties of the upper airways could fully explain this behavior. Steady inspiratory flows through the upper airways in anesthetized supine newborn kittens and puppies resulted in upper airway obstruction, even at flows less than those occurring during resting breathing, suggesting that in the unanesthetized condition muscle tone plays an important role in maintaining upper airway patency. Mouth (Rm) and nose (Rn) resistances have been measured during steady expiratory flows with nostrils closed and mouth passively open or nostrils open and mouth closed. In all the newborns, Rn was substantially smaller than Rm. In contrast, the Rn/Rm in adult dogs is greater than unity. In adult cats Rn/Rm is above or below unity depending upon the flow rate, but the ratio is always larger than in newborn kittens. The difference between newborns and adults is entirely due to the small Rn of the newborn, as Rm is not greater in the newborn than in the adult. We conclude that the obligatory nose breathing behavior of newborns is not fully explained by the passive mechanical properties of the upper airways.

Upper airway obstruction induced by negative-pressure ventilation in awake healthy subjects

1993 ◽  
Vol 75 (2) ◽  
pp. 546-552 ◽  
Author(s):  
A. Sanna ◽  
C. Veriter ◽  
D. Stanescu
Keyword(s):  
Airway Obstruction ◽  
Negative Pressure ◽  
Healthy Subjects ◽  
Fiber Optic ◽  
Upper Airway ◽  
Upper Airway Obstruction ◽  
Bipolar Electrode ◽  
Upper Airways ◽  
Negative Pressure Ventilation ◽  
Zero Values

Negative-pressure ventilation (NPV) induces sleep-related upper airway obstruction. However, the precise mechanism and site of upper airway obstruction during NPV have not been worked out. We studied seven awake healthy volunteers (23–30 yr old) in an Emerson tank respirator. Subjects had the head outside the iron lung and breathed through a pneumotachograph, which yielded the airflow (V) signal. Supraglottic pressure (Psg) was measured with a catheter with the tip at the retroepiglottic level. Diaphragmatic electromyograms (EMGdi) were obtained from an esophageal bipolar electrode. Tidal volume was measured with an inductance plethysmograph. Measurements were done at -10, -20, and -30 cmH2O. At each pressure run subjects were asked to repeatedly relax or to actively breathe in phase with the respirator. Subjects had been previously trained to relax during NPV. During the relax runs there was no EMGdi activity. Stridor or wheezing occurred in all seven subjects during the relax runs but not during the active runs. Two patterns were associated with NPV during relax runs. One pattern was decreases in both V and Psg followed by zero values of these indexes, which corresponded to an inspiratory narrowing and closure of the glottis. These changes were visualized by fiber-optic bronchoscopy in one subject. The second pattern was a decrease in V and increase in Psg, which corresponded to an inspiratory supraglottic obstruction. In five subjects a supraglottic pattern was observed, whereas in two subjects glottic closure was seen. We conclude that muscular relaxation during NPV produces a decrease in the caliber of the upper airways at the glottic or supraglottic level. An uncoupling of upper airway muscle activity and the diaphragm might be the mechanism responsible for these changes.

scholarly journals Double Barrel Nasal Trumpets to Prevent Upper Airway Obstruction after Nasal and Non-Nasal Surgery

2018 ◽  
Vol 2018 ◽  
pp. 1-6
Author(s):  
Macario Camacho ◽  
Justin M. Wei ◽  
Lauren K. Reckley ◽  
Sungjin A. Song
Keyword(s):  
Obstructive Sleep Apnea ◽  
Sleep Apnea ◽  
Airway Obstruction ◽  
Upper Airway ◽  
Upper Airway Obstruction ◽  
Morbidly Obese ◽  
Obese Patients ◽  
Nasal Surgery ◽  
Upper Airways ◽  
Obstructive Sleep

Objectives. During anesthesia emergence, patients are extubated and the upper airway can become vulnerable to obstruction. Nasal trumpets can help prevent obstruction. However, we have found no manuscript describing how to place nasal trumpets after nasal surgery (septoplasties or septorhinoplasties), likely because (1) the lack of space with nasal splints in place and (2) surgeons may fear that removing the trumpets could displace the splints. The objective of this manuscript is to describe how to place nasal trumpets even with nasal splints in place. Materials and Methods. The authors describe techniques (Double Barrel Technique and Modified Double Barrel Technique) that were developed over three years ago and have been used in patients with obstructive sleep apnea (OSA) and other patients who had collapsible or narrow upper airways (i.e., morbidly obese patients). Results. The technique described in the manuscript provides a method for placing one long and one short nasal trumpet in a manner that helps prevent postoperative upper airway obstruction. The modified version describes a method for placing nasal trumpets even when there are nasal splints in place. Over one-hundred patients have had nasal trumpets placed without postoperative oxygen desaturations. Conclusions. The Double Barrel Technique allows for a safe emergence from anesthesia in patients predisposed to upper airway obstruction (such as in obstructive sleep apnea and morbidly obese patients). To our knowledge, the Modified Double Barrel Technique is the first description for the use of nasal trumpets in patients who had nasal surgery and who have nasal splints in place.

scholarly journals Unusual presentation of ectopic thyroid causing respiratory distress

2020 ◽  
Vol 6 (6) ◽  
pp. 1188
Author(s):  
Sunil Kathuria ◽  
Chikku Sunny
Keyword(s):  
Airway Obstruction ◽  
English Literature ◽  
Thyroid Tissue ◽  
Upper Airway ◽  
Upper Airway Obstruction ◽  
Ectopic Thyroid ◽  
Respiratory Obstruction ◽  
Upper Airways ◽  
Ectopic Thyroid Tissue ◽  
Foreign Body Inhalation

<p>Internal obstruction of the upper airways can be due to infection, anaphylactic reaction, congenital anomaly, foreign body inhalation or mass. The endoluminal presence of thyroid tissue in the trachea is a rare cause of airway obstruction. Only 14 well documented cases of intratracheal ectopic thyroid tissue have been reported in English literature since 1966. These lesions are mostly benign and nearly all patient present with symptoms of respiratory obstruction. This case report is of a lady who presented with upper airway obstruction due to subglottic ectopic thyroid tissue. An ectopic thyroid gland can develop if its normal migration is halted along this tract during embryogenesis. Subglottic location of ectopic thyroid is extremely rare. However, ectopic thyroid tissue in the larynx should be considered as a possible diagnosis causing upper airway obstruction.</p>

Susceptibility to Upper Airway Obstruction during Partial Neuromuscular Block 

1998 ◽  
Vol 88 (2) ◽  
pp. 371-378 ◽  
Author(s):  
Gilles D'Honneur ◽  
Frederic Lofaso ◽  
Gordon B. Drummond ◽  
Jean-Marc Rimaniol ◽  
Jean V. Aubineau ◽  
...  
Keyword(s):  
Carbon Dioxide ◽  
Airway Obstruction ◽  
Airway Resistance ◽  
Neuromuscular Block ◽  
Work Of Breathing ◽  
Upper Airway ◽  
Residual Effects ◽  
Airway Patency ◽  
Upper Airway Resistance ◽  
Residual Neuromuscular Block

Background Airway obstruction after anesthesia may be caused or exaggerated by residual neuromuscular block, with loss of muscle support for collapsible upper airway structures. Methods Six male volunteers were studied before treatment, during stable partial neuromuscular block with vecuronium at a mean train-of-four (TOF) ratio of 50% (95% CI, 36-61%), and after reversal by neostigmine. Catheter-mounted transducers were placed in the pharynx and esophagus to estimate, respectively, the upper airway resistance, and the work of breathing (calculated as the time integral of the inspiratory pressure developed by the respiratory muscles, esophageal pressure time product) during quiet breathing, during breathing 5% carbon dioxide, and while breathing with an inspiratory resistor. Breathing with pressure at the airway opening held at pressures from -5 to 40 cm H2O were also tested to assess airway collapsibility. Results Although breathing through a resistor increased upper airway resistance from 1.2 (0.67, 1.72) cm H2O x l(-1) x s to 2.5 (1.32, 3.38) cm H2O x l(-1) x s, and carbon dioxide stimulation reduced resistance to 0.8 (0.46, 1.33) cm H2O x l(-1) x s, no effect of partial neuromuscular block (mean TOF ratio, 52%) on upper airway properties could be shown. Conclusions Neuromuscular block with a TOF ratio of 50% can be present yet clinically difficult to detect in patients recovering from anesthesia. This degree of block has no effect on airway patency in volunteers, even during challenge. Airway obstruction during recovery from anesthesia thus is more likely to be caused by residual effects of general anesthetic agents or centrally acting analgesics, either alone or perhaps in concert with residual neuromuscular block.

scholarly journals Site and mechanics of spontaneous, sleep-associated obstructive apnea in infants

2000 ◽  
Vol 89 (6) ◽  
pp. 2453-2462 ◽  
Author(s):  
Garrick W. Don ◽  
Turkka Kirjavainen ◽  
Catherine Broome ◽  
Chris Seton ◽  
Karen A. Waters
Keyword(s):  
Airway Obstruction ◽  
Airway Resistance ◽  
Upper Airway ◽  
Magnetic Resonance Images ◽  
Upper Airway Obstruction ◽  
Older Children ◽  
Obstructive Apnea ◽  
Obstructive Sleep ◽  
Lumen Catheter ◽  
Overnight Polysomnography

To examine the mechanics of infantile obstructive sleep apnea (OSA), airway pressures were measured using a triple-lumen catheter in 19 infants (age 1–36 wk), with concurrent overnight polysomnography. Catheter placement was guided by correlations between measurements of magnetic resonance images and body weight of 70 infants. The level of spontaneous obstruction was palatal in 52% and retroglossal in 48% of all events. Palatal obstruction predominated in infants treated for OSA (80% of events), compared with 38.6% from infants with infrequent events ( P = 0.02). During obstructive events, successive respiratory efforts increased in amplitude (mean intrathoracic pressures −11.4, −15.0, and −20.4 cmH2O; ANOVA, P < 0.05), with arousal after only 29% of the obstructive and mixed apneas. The soft palate is commonly involved in the upper airway obstruction of infants suffering OSA. Postterm, infant responses to upper airway obstruction are intermediate between those of preterm infants and older children, with infrequent termination by arousal but no persisting “upper airway resistance” and respiratory efforts exceeding baseline during the event.

Induction of periodic breathing during sleep causes upper airway obstruction in humans

1986 ◽  
Vol 61 (4) ◽  
pp. 1438-1443 ◽  
Author(s):  
E. Onal ◽  
D. L. Burrows ◽  
R. H. Hart ◽  
M. Lopata
Keyword(s):  
Airway Obstruction ◽  
Upper Airway ◽  
Periodic Breathing ◽  
Nrem Sleep ◽  
Upper Airway Obstruction ◽  
Respiratory Pattern ◽  
Normal Male ◽  
Added Resistance ◽  
Upper Airways ◽  
Resistive Loading

To test the hypothesis that occlusive apneas result from sleep-induced periodic breathing in association with some degree of upper airway compromise, periodic breathing was induced during non-rapid-eye-movement (NREM) sleep by administering hypoxic gas mixtures with and without applied external inspiratory resistance (9 cmH2O X l-1 X s) in five normal male volunteers. In addition to standard polysomnography for sleep staging and respiratory pattern monitoring, esophageal pressure, tidal volume (VT), and airflow were measured via an esophageal catheter and pneumotachograph, respectively, with the latter attached to a tight-fitting face mask, allowing calculation of total pulmonary system resistance (Rp). During stage I/II NREM sleep minimal period breathing was evident in two of the subjects; however, in four subjects during hypoxia and/or relief from hypoxia, with and without added resistance, pronounced periodic breathing developed with waxing and waning of VT, sometimes with apneic phases. Resistive loading without hypoxia did not cause periodicity. At the nadir of periodic changes in VT, Rp was usually at its highest and there was a significant linear relationship between Rp and 1/VT, indicating the development of obstructive hypopneas. In one subject without added resistance and in the same subject and in another during resistive loading, upper airway obstruction at the nadir of the periodic fluctuations in VT was observed. We conclude that periodic breathing resulting in periodic diminution of upper airway muscle activity is associated with increased upper airway resistance that predisposes upper airways to collapse.

Evaluation of upper airway obstruction after partial laryngectomies by radiological method and flow–volume loop analysis

1994 ◽  
Vol 108 (11) ◽  
pp. 954-956 ◽  
Author(s):  
M. Misiolek ◽  
D. Ziora ◽  
K. Oklek ◽  
G. Namyslowski
Keyword(s):  
Airway Obstruction ◽  
Chronic Bronchitis ◽  
Upper Airway ◽  
Upper Airway Obstruction ◽  
Radiological Examination ◽  
Flow Volume ◽  
Loop Analysis ◽  
Upper Airways ◽  
Flow Volume Loop ◽  
Airway Obstructions

AbstractAnatomical and functional estimations of the upper airways in patients after partial laryngectomies (cordectomy, hemilaryngectomy, enlarged hemilaryngectomy) carried out due to cancer are discussed in this paper. The post-operative lumen of the larynx and the trachea were estimated by radiological examination. The coefficient larynx/trachea (L/T) was proposed to describe fixed obstruction.At the same time, all patients underwent spirometric examinations. Inspiratory and expiratory parameters of the flow-volume loop were evaluated. In 39 patients the L/T coefficient was lower than in a group of patients with chronic bronchitis (P<0.05). Also inspiratory and some expiratory parameters of the flow–volume loop decreased in contrast to the group with chronic bronchitis. All results showed the usefulness of radiological and spirometric methods in detecting upper airway obstructions and confirmed their fixed character. The influence of the area of operation on the degree of upper airway obstruction was emphasized.

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