Expiratory flow limitation and intrinsic positive end-expiratory pressure in obesity

1998 ◽  
Vol 85 (4) ◽  
pp. 1236-1243 ◽  
Author(s):  
W. Pankow ◽  
T. Podszus ◽  
T. Gutheil ◽  
T. Penzel ◽  
J.-H. Peter ◽  
...  
Keyword(s):  
Supine Position ◽  
Lateral Position ◽  
Normal Weight ◽  
Upright Position ◽  
Flow Limitation ◽  
Positive End Expiratory Pressure ◽  
Expiratory Flow Limitation ◽  
Transdiaphragmatic Pressure ◽  
Expiratory Flow ◽  
The Right

Breathing at very low lung volumes might be affected by decreased expiratory airflow and air trapping. Our purpose was to detect expiratory flow limitation (EFL) and, as a consequence, intrinsic positive end-expiratory pressure (PEEPi) in grossly obese subjects (OS). Eight OS with a mean body mass index (BMI) of 44 ± 5 kg/m2 and six age-matched normal-weight control subjects (CS) were studied in different body positions. Negative expiratory pressure (NEP) was used to determine EFL. In contrast to CS, EFL was found in two of eight OS in the upright position and in seven of eight OS in the supine position. Dynamic PEEPi and mean transdiaphragmatic pressure (mean Pdi) were measured in all six CS and in six of eight OS. In OS, PEEPi increased from 0.14 ± 0.06 (SD) kPa in the upright position to 0.41 ± 0.11 kPa in the supine position ( P < 0.05) and decreased to 0.20 ± 0.08 kPa in the right lateral position ( P < 0.05, compared with supine), whereas, in CS, PEEPi was significantly smaller (<0.05 kPa) in each position. In OS, mean Pdi in each position was significantly larger compared with CS. Mean Pdi increased from 1.02 ± 0.32 kPa in the upright position to 1.26 ± 0.17 kPa in the supine position (not significant) and decreased to 1.06 ± 0.26 kPa in the right lateral position ( P < 0.05, compared with supine), whereas there were no significant changes in CS. We conclude that in OS 1) tidal breathing can be affected by EFL and PEEPi; 2) EFL and PEEPi are promoted by the supine posture; and 3) the increased diaphragmatic load in the supine position is, in part, related to PEEPi.

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

2020 ◽  
Vol 56 (3) ◽  
pp. 1902234 ◽  
Author(s):  
Eui-Sik Suh ◽  
Pasquale Pompilio ◽  
Swapna Mandal ◽  
Peter Hill ◽  
Georgios Kaltsakas ◽  
...  
Keyword(s):  
Respiratory Failure ◽  
Chronic Respiratory Failure ◽  
Forced Oscillation Technique ◽  
Flow Limitation ◽  
Positive End Expiratory Pressure ◽  
Tidal Breathing ◽  
Expiratory Flow Limitation ◽  
Transdiaphragmatic Pressure ◽  
Expiratory Flow ◽  
Severe Copd

BackgroundThe 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.MethodsPatients 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 (ΔPdi), transdiaphragmatic pressure–time product (PTPdi) and PEEPi, between EPAP levels 2 cmH2O below to 3 cmH2O above optimal EPAP.ResultsOf 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−1versus 16.8±8.8 cmH2O·s−1; p<0.05) and ΔPdi (12.4±7.8 cmH2O versus 18.2±5.1 cmH2O; p<0.05) were reduced at optimal EPAP+1 cmH2O compared with baseline.ConclusionAutotitration of EPAP, using a FOT-based algorithm to abolish EFLT, minimises transdiaphragmatic pressure swings and NRD in patients with COPD and chronic respiratory failure.

Lung and chest wall mechanics in patients with acute respiratory distress syndrome, expiratory flow limitation, and airway closure

2020 ◽  
Vol 128 (6) ◽  
pp. 1594-1603 ◽  
Author(s):  
Claude Guérin ◽  
Nicolas Terzi ◽  
Louis-Marie Galerneau ◽  
Mehdi Mezidi ◽  
Hodane Yonis ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Distress Syndrome ◽  
Flow Limitation ◽  
Airway Closure ◽  
Positive End Expiratory Pressure ◽  
Expiratory Flow Limitation ◽  
Lung Elastance ◽  
Chest Wall Mechanics ◽  
Expiratory Flow ◽  
Better Than

Expiratory flow limitation (EFL) and airway closure (AC) were observed in 32% and 52%, respectively, of 25 patients with ARDS investigated during mechanical ventilation in supine position with a positive end-expiratory pressure of 5 cmH2O. The performance of dynamic lung elastance to detect expiratory flow limitation was good and better than that to detect airway closure. The vast majority of patients with EFL also had AC; however, AC can occur in the absence of EFL.

scholarly journals Ventilatory and perceptual responses to cycle exercise in obese women

2007 ◽  
Vol 102 (6) ◽  
pp. 2217-2226 ◽  
Author(s):  
Dror Ofir ◽  
Pierantonio Laveneziana ◽  
Katherine A. Webb ◽  
Denis E. O'Donnell
Keyword(s):  
Metabolic Cost ◽  
Normal Weight ◽  
Flow Limitation ◽  
Obese Women ◽  
Cycle Exercise ◽  
Expiratory Flow Limitation ◽  
Relative Contribution ◽  
Mechanical Factors ◽  
Expiratory Flow ◽  
Relationship Of

The main purpose of this study was to examine the relative contribution of respiratory mechanical factors and the increased metabolic cost of locomotion to exertional breathlessness in obese women. We examined the relationship of intensity of breathlessness to ventilation (V̇e) when exertional oxygen uptake (V̇o2) of obesity was minimized by cycle exercise. Eighteen middle-aged (54 ± 8 yr, mean ± SD) obese [body mass index (BMI) 40.2 ± 7.8 kg/m2] and 13 age-matched normal-weight (BMI 23.3 ± 1.7 kg/m2) women were studied. Breathlessness at higher submaximal cycle work rates was significantly increased (by ≥1 Borg unit) in obese compared with normal-weight women, in association with a 35–45% increase in V̇e and a higher metabolic cost of exercise. Obese women demonstrated greater resting expiratory flow limitation, reduced resting end-expiratory lung volume (EELV)(by 20%), and progressive increases in dynamic EELV during exercise: peak inspiratory capacity (IC) decreased by 16% (0.39 liter) of the resting value. V̇e/V̇o2 slopes were unchanged in obesity. Breathlessness ratings at any given V̇e or V̇o2 were not increased in obesity, suggesting that respiratory mechanical factors were not contributory. Our results indicate that in obese women, recruitment of resting IC and dynamic increases in EELV with exercise served to optimize operating lung volumes and to attenuate expiratory flow limitation so as to accommodate the increased ventilatory demand without increased breathlessness.

Effect of negative expiratory pressure on respiratory system flow resistance in awake snorers and nonsnorers

1999 ◽  
Vol 87 (3) ◽  
pp. 969-976 ◽  
Author(s):  
Claudio Tantucci ◽  
Alexandre Duguet ◽  
Anna Ferretti ◽  
Selma Mehiri ◽  
Isabelle Arnulf ◽  
...  
Keyword(s):  
Respiratory System ◽  
Supine Position ◽  
Flow Resistance ◽  
Upper Airway ◽  
Flow Limitation ◽  
Expiratory Flow Limitation ◽  
Upper Airways ◽  
Flow Interruption ◽  
Expiratory Flow ◽  
Spontaneously Breathing

In spontaneously breathing subjects, intrathoracic expiratory flow limitation can be detected by applying a negative expiratory pressure (NEP) at the mouth during tidal expiration. To assess whether NEP might increase upper airway resistance per se, the interrupter resistance of the respiratory system (Rint,rs) was computed with and without NEP by using the flow interruption technique in 12 awake healthy subjects, 6 nonsnorers (NS), and 6 nonapneic snorers (S). Expiratory flow (V˙) and Rint,rs were measured under control conditions with V˙ increased voluntarily and during random application of brief (0.2-s) NEP pulses from −1 to −7 cmH2O, in both the seated and supine position. In NS, Rint,rs with spontaneous increase inV˙ and with NEP was similar [3.10 ± 0.19 and 3.30 ± 0.18 cmH2O ⋅ l−1 ⋅ s at spontaneous V˙ of 1.0 ± 0.01 l/s and atV˙ of 1.1 ± 0.07 l/s with NEP (−5 cmH2O), respectively]. In S, a marked increase in Rint,rs was found at all levels of NEP ( P < 0.05). Rint,rs was 3.50 ± 0.44 and 8.97 ± 3.16 cmH2O ⋅ l−1 ⋅ s at spontaneous V˙ of 0.81 ± 0.02 l/s and atV˙ of 0.80 ± 0.17 l/s with NEP (−5 cmH2O), respectively ( P < 0.05). With NEP, Rint,rs was markedly higher in S than in NS both seated ( F = 8.77; P < 0.01) and supine ( F = 9.43; P < 0.01). In S,V˙ increased much less with NEP than in NS and was sometimes lower than without NEP, especially in the supine position. This study indicates that during wakefulness nonapneic S have more collapsible upper airways than do NS, as reflected by the marked increase in Rint,rs with NEP. The latter leads occasionally to an actual decrease in V˙ such as to invalidate the NEP method for detection of intrathoracic expiratory flow limitation.

Intrinsic positive end-expiratory pressure in mechanically ventilated patients with and without tidal expiratory flow limitation

2000 ◽  
Vol 28 (12) ◽  
pp. 3837-3842 ◽  
Author(s):  
Apostolos Armaganidis ◽  
Krystallia Stavrakaki-Kallergi ◽  
Antonia Koutsoukou ◽  
Andreas Lymberis ◽  
Joseph Milic-Emili ◽  
...  
Keyword(s):  
Flow Limitation ◽  
Positive End Expiratory Pressure ◽  
Expiratory Flow Limitation ◽  
Mechanically Ventilated ◽  
Mechanically Ventilated Patients ◽  
Expiratory Flow ◽  
Ventilated Patients

Modeling expiratory flow from excised tracheal tube laws

1999 ◽  
Vol 87 (5) ◽  
pp. 1973-1980 ◽  
Author(s):  
Nikolai Aljuri ◽  
Lutz Freitag ◽  
José G. Venegas
Keyword(s):  
Static Pressure ◽  
Pressure Recovery ◽  
High Frequency Ventilation ◽  
Flow Limitation ◽  
Flow Conditions ◽  
Expiratory Flow Limitation ◽  
Elastic Tubes ◽  
Viscous Losses ◽  
Forced Expiratory Flow ◽  
Expiratory Flow

Flow limitation during forced exhalation and gas trapping during high-frequency ventilation are affected by upstream viscous losses and by the relationship between transmural pressure (Ptm) and cross-sectional area ( A tr) of the airways, i.e., tube law (TL). Our objective was to test the validity of a simple lumped-parameter model of expiratory flow limitation, including the measured TL, static pressure recovery, and upstream viscous losses. To accomplish this objective, we assessed the TLs of various excised animal tracheae in controlled conditions of quasi-static (no flow) and steady forced expiratory flow. A tr was measured from digitized images of inner tracheal walls delineated by transillumination at an axial location defining the minimal area during forced expiratory flow. Tracheal TLs followed closely the exponential form proposed by Shapiro (A. H. Shapiro. J. Biomech. Eng. 99: 126–147, 1977) for elastic tubes: Ptm = K p[( A tr/ A tr0)− n − 1], where A tr0 is A tr at Ptm = 0 and K p is a parametric factor related to the stiffness of the tube wall. Using these TLs, we found that the simple model of expiratory flow limitation described well the experimental data. Independent of upstream resistance, all tracheae with an exponent n < 2 experienced flow limitation, whereas a trachea with n > 2 did not. Upstream viscous losses, as expected, reduced maximal expiratory flow. The TL measured under steady-flow conditions was stiffer than that measured under expiratory no-flow conditions, only if a significant static pressure recovery from the choke point to atmosphere was assumed in the measurement.

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