在重度慢性阻塞性肺疾病患者潮气呼吸期间自动滴定外部呼气末正压以消除呼气气流受限：一项生理学研究

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

作者信息

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

机构信息

Lane Fox Respiratory Service, Guy's and St Thomas' NHS Foundation Trust, London, UK.

Faculty of Life Sciences and Medicine, King's College London, London, UK.

出版信息

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

DOI:10.1183/13993003.02234-2019

PMID:32444404

Abstract

BACKGROUND

The optimal noninvasive application of external positive end-expiratory pressure (EPAP) to abolish tidal-breathing expiratory flow limitation (EFL) and minimise intrinsic positive end-expiratory pressure (PEEP) is challenging in COPD patients. We investigated whether auto-titrating EPAP, using the forced oscillation technique (FOT) to detect and abolish EFL, would minimise PEEP, 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. Once optimal EPAP was identified, manual titration was performed to assess NRD (using diaphragm and parasternal intercostal muscle electromyography, EMG and EMG, respectively), transdiaphragmatic inspiratory pressure swings (Δ ), transdiaphragmatic pressure-time product (PTP) and PEEP, between EPAP levels 2 cmHO below to 3 cmHO above optimal EPAP.

RESULTS

Of 10 patients enrolled (age 65±6 years; male 60%; body mass index 27.6±7.2 kg.m; forced expiratory volume in 1 s 28.4±8.3% predicted), eight had EFL, and optimal EPAP was 9 (range 4-13) cmHO. NRD was reduced from baseline EPAP at 1 cmHO below optimal EPAP on EMG and at optimal EPAP on EMG. In addition, at optimal EPAP, PEEP (0.80±1.27 cmHO 1.95± 1.70 cmHO; p<0.05) was reduced compared with baseline. PTP (10.3±7.8 cmHO·s 16.8±8.8 cmHO·s; p<0.05) and Δ (12.4±7.8 cmHO 18.2±5.1 cmHO; p<0.05) were reduced at optimal EPAP+1 cmHO compared with baseline.

CONCLUSION

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

摘要

背景

在慢性阻塞性肺疾病（COPD）患者中，如何以最佳方式无创应用外部呼气末正压（EPAP）来消除潮气呼吸呼气流量受限（EFL）并使内源性呼气末正压（PEEP）最小化具有挑战性。我们研究了使用强迫振荡技术（FOT）检测并消除EFL的自动滴定EPAP是否能使重度COPD患者的PEEP、呼吸功和神经呼吸驱动（NRD）最小化。

方法

患有慢性呼吸衰竭的COPD患者使用基于FOT的算法进行EPAP自动滴定，该算法可检测EFL。一旦确定最佳EPAP，进行手动滴定以评估在比最佳EPAP低2 cmH₂O至高3 cmH₂O的EPAP水平之间的NRD（分别使用膈肌和胸骨旁肋间肌肌电图，即EMG和EMG）、跨膈吸气压力波动（Δ）、跨膈压力-时间乘积（PTP）和PEEP。

结果

纳入的10例患者（年龄65±6岁；男性60%；体重指数27.6±7.2 kg/m²；第1秒用力呼气量为预测值的28.4±8.3%）中，8例存在EFL，最佳EPAP为9（范围4 - 13）cmH₂O。在肌电图上，NRD在比最佳EPAP低1 cmH₂O时较基线EPAP降低，在最佳EPAP时在肌电图上也降低。此外，在最佳EPAP时，与基线相比，PEEP（0.80±1.27 cmH₂O对1.95±1.70 cmH₂O；p<0.05）降低。与基线相比，在最佳EPAP + 1 cmH₂O时PTP（10.3±7.8 cmH₂O·s对16.8±8.8 cmH₂O·s；p<0.05）和Δ（12.4±7.8 cmH₂O对18.2±5.1 cmH₂O；p<0.05）降低。