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

Sonia Khirani,Brigitte Fauroux,Nicolas Leboulanger,Arnaud Picard,Sabrina Aloui,Adriana Ramirez

doi:10.1186/cc12846

Abstract

aIntroductionNoninvasive continuous positive airway pressure (CPAP) is recognized as an effective treatment for severe airway obstruction in young children. The aim of the present study was to compare a clinical setting with a physiological setting of noninvasive CPAP in infants with nocturnal alveolar hypoventilation due to severe upper airway obstruction (UAO) or bronchopulmonary dysplasia (BPD).MethodsThe breathing pattern and respiratory muscle output of all consecutive infants due to start CPAP in our noninvasive ventilation unit were retrospectively analysed. CPAP set on clinical noninvasive parameters (clinical CPAP) was compared to CPAP set on the normalization or the maximal reduction of the oesophageal pressure (Poes) and transdiaphragmatic pressure (Pdi) swings (physiological CPAP). Expiratory gastric pressure (Pgas) swing was measured.ResultsThe data of 12 infants (mean age 10 ± 8 mo) with UAO (n = 7) or BPD (n = 5) were gathered. The mean clinical CPAP (8 ± 2 cmH2O) was associated with a significant decrease in Poes and Pdi swings. Indeed, Poes swing decreased from 31 ± 15 cmH2O during spontaneous breathing to 21 ± 10 cmH2O during CPAP (P < 0.05). The mean physiological CPAP level was 2 ± 2 cmH2O higher than the mean clinical CPAP level and was associated with a significantly greater improvement in all indices of respiratory effort (Poes swing 11 ± 5 cm H2O; P < 0.05 compared to clinical CPAP). Expiratory abdominal activity was present during the clinical CPAP and decreased during physiological CPAP.ConclusionsA physiological setting of noninvasive CPAP, based on the recording of Poes and Pgas, is superior to a clinical setting, based on clinical noninvasive parameters. Expiratory abdominal activity was present during spontaneous breathing and decreased in the physiological CPAP setting.

Highlights

Noninvasive continuous positive airway pressure (CPAP) is recognized as an effective treatment for severe airway obstruction in young children
CPAP set on clinical noninvasive parameters was compared to CPAP set on the normalization or the maximal reduction of the oesophageal pressure (Poes) and transdiaphragmatic pressure (Pdi) swings
This study shows that a CPAP setting based on clinical noninvasive parameters is associated with an improvement in breathing pattern and respiratory effort in infants with severe upper airway obstruction (UAO) or bronchopulmonary dysplasia (BPD), but this improvement is significantly greater with an invasive physiological setting based on the monitoring of Poes and Pgas tracings

Summary

Introduction

Noninvasive continuous positive airway pressure (CPAP) is recognized as an effective treatment for severe airway obstruction in young children. Some other diseases involving the lower respiratory tract, such as chronic lung diseases of prematurity, called bronchopulmonary dysplasia (BPD), are associated with lung diseases and predominantly peripheral airway obstruction, which may be severe and cause intrinsic positive end-expiratory pressure (PEEPi). Because of these differences in pathophysiology and the lack of guidelines for this age group, the titration of CPAP in infants is generally based on clinical parameters such as the disappearance of the stridor and retractions, the decrease in respiratory and heart rates and the normalization of gas exchange [2,3]. To facilitate the acclimatization of the infant with CPAP, the initial level is usually set at 4 cmH2O, followed by a gradual increase of the CPAP level until the best clinical efficacy and comfort are obtained

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