Assessment Of Respiratory Effort Research Articles

Mandibular jaw movements as a non-invasive measure of respiratory effort during sleep: application in clinical practice

Assessment of respiratory effort (RE) is key for characterization of respiratory events. The discrimination between central and obstructive events is important because these events are caused by different physio-pathological mechanisms and require different treatment approaches. Many of the currently available options for home sleep apnea testing either do not measure RE, or RE signal recording is not always reliable. This is due to a variety of factors, including for instance wrong placement of the respiratory inductance plethysmography (RIP) sensors leading to artifacts or signal loss. Monitoring of mandibular jaw movements (MJM) provides the ability to accurately measure RE through a single point of contact sensor placed on the patient's chin. The inertial unit included in the capturing technology and overnight positional stability of the sensor provide a robust MJM bio-signal to detect sleep-disordered breathing (SDB). Many of the pharyngeal muscles are attached to the mandible directly, or indirectly via the hyoid bone. The motor trigeminal nerve impulses to contract or relax these muscles generate discrete MJM that reflect changes in RE during sleep. Indeed, the central drive utilizes the lower jaw as a fine-tuning lever to stiffen the upper airway musculature and safeguard the patency of the pharynx. Associations between the MJM bio-signal properties and both physiological and pathological breathing patterns during sleep have been extensively studied. These show a close relationship between changes in the MJM bio-signal as a function of RE that is similar to levels of RE measured simultaneously by the reference bio-signals such as esophageal pressure or crural diaphragmatic electromyography. Specific waveforms, frequencies, and amplitudes of these discrete MJM are seen across a variety of breathing disturbances that are recommended to be scored by the American Academy of Sleep Medicine. Moreover, MJM monitoring provides information about sleep/wake states and arousals, which enables total sleep time measurement for accurate calculation of conventional hourly indices. The MJM bio-signal can be interpreted and its automatic analysis using a dedicated machine learning algorithm delivers a comprehensive and clinically informative study report that provides physicians with the necessary information to aid in the diagnosis of SDB.

Respiratory Monitoring at Bedside in COVID-19 Patients.

The SARS-CoV-2 (COVID-19) pandemic has forced some reflections to be had surrounding the ventilatory support to be applied to certain types of patients. The model of two phenotypes, set out by Professor Gattinoni and colleagues, suggests that adequate monitoring of respiratory effort may play a key role in the treatment of respiratory failure due to COVID-19. An insufficient control of the patient’s respiratory efforts could lead to an aggravation of lung damage, mainly due to the possibility of generating Patient Self-Inflicted Lung Injury (PSILI) with a consequent aggravation of the pathological picture. Nevertheless, effectively monitoring the patient’s respiratory work, especially in nonintensive settings, is not easy. This article briefly describes some methods that allow the assessment of respiratory effort, such as the use of ultrasound and respiratory tests, which can be performed in nonintensive settings.

Role of esophageal manometry in polysomnography of patients with chronic respiratory failure.

Esophageal pressure (Pes) monitoring is performed during polysomnography (PSG) with a thin, water-filled catheter connected to a transducer. The resulting quantitative assessment of respiratory effort can aid in the accurate diagnosis of sleep-related breathing disorders. This was a prospective observational study using Pes in PSG for thirty patients with chronic respiratory failure (CRF) conducted in the Department of Pulmonary, Critical Care and Sleep Medicine at a tertiary care centre of North India. Sleep scoring was done by conventional method and using esophageal manometry and compared polysomnography normal without esophageal manometry recording (PSGN) and polysomnography with esophageal manometry scoring (PSGE). Apnea hypopnea index (AHI) index was similar in both groups. However, respiratory effort related arousals (RERAs) were diagnosed easily using Pes resulting in significant increase in respiratory disturbance index (RDI) and even reclassification in terms of severity of sleep apnea. Besides, Pes was also useful to distinguish obstructive from central hypopnea which cannot be distinguished by routine PSG which can help guide therapy particularly in chronic respiratory failure patients with hypoventilation. Such patients with hypoventilation often require bilevel positive airway pressure as ventilatory support. Central hypopneas and apneas with hypercapnia may require higher-pressure support, a backup rate or even advanced volume assured modes of ventilation. Thus, it can be concluded that Pes in PSG remains a safe and generally well-tolerated procedure. Use of Pes aids to detect RERA and thereby RDI; a better marker of sleep-related breathing disorder rather than AHI. It also helps in differentiating between obstructive and central hypopnea.

Assessment of respiratory effort with EMG extracted from ECG recordings during prolonged breath holds: Insights into obstructive apnea and extreme physiology.

Breath holding divers display extraordinary voluntary control over involuntary reactions during apneic episodes. After an initial easy phase to the breath hold, this voluntary control is applied against the increasing involuntary effort to inspire. We quantified an electromyographic (EMG) signal associated with respiratory movements derived from broad bandpass ECG recordings taken from experienced breath holding divers during prolonged dry breath holds. We sought to define their relationship to involuntary respiratory movements and compare these signals with what is known to occur in obstructive sleep apnea (OSA) and epileptic seizures. ECG and inductance plethysmography records from 14 competitive apneists (1 female) were analyzed. ECG records were analyzed for intervals and the EMG signal was extracted from a re‐filtered version of the original broad bandpass signal and ultimately enveloped with a Hilbert transform. EMG burst magnitude, quantified as an area measure, increased over the course of the struggle phase, correlated with inductance plethysmography measures, and corresponded to significant variance in heart rate variability. We conclude that an EMG signal extracted from the ECG can complement plethysmography during breath holds and may help quantify involuntary effort, as reported previously for obstructive sleep apnea. Further, given the resemblance between cardiac and respiratory features of the breath hold struggle phase to obstructive apnea that can occur during sleep or in association with epileptic seizure activity, the struggle phase may be a useful simulation of obstructive apnea for controlled experimentation that can help clarify aspects of acute and chronic apnea‐associated physiology.

Relationship between Knowledge-Skill and Importance of Physical Examination for Children Admitted to Infectious Wards: Examining Nurses’ Points of View

Background: A careful, timely, and accurate examination of patients by nurses provides grounds for maintaining and improving patients' safety in hospitals. Proper examination of the health status of children and, consequently, an accurate nursing diagnosis can accelerate their recovery and can have positive effects on the family. Objectives: This study aimed to determine the relationship between knowledge-skill and the importance of physical examination of children admitted to infectious wards from the perspective of nurses working in Ilam hospitals in 2017. Methods: In this descriptive cross-sectional study, 150 nurses were selected using purposive sampling. To collect data, the demographic information questionnaire, physical examination knowledge-skill scale, and physical examination importance questionnaire were employed. Data were analyzed using the SPSS version 18. In addition, descriptive statistics (mean, standard deviation, frequency, and percentage) and inferential tests (independent and paired sample t-tests) were used. Results: The findings revealed that the acquired knowledge-skill mean score was 100.86 out of 200. The nurses exhibited higher levels of knowledge-skill with regard to controlling vital signs, assessment of respiratory effort, observation of skin color, and touching the extremities to check the body temperature. In contrast, they exhibited lower levels of knowledge-skill in terms of examination of the breast to assess lumps, examination of the spine, assessing how the patient is talking, and listening to lung sounds. Additionally, there was a significant positive correlation between knowledge-skill and the importance of pediatric physical examinations (P < 0.05). Conclusions: Considering that the mean score of nurses in terms of the knowledge-skill required for conducting pediatric physical examination was low, appropriate interventions should be planned by nursing managers to improve the status of nurses' knowledge-skill in this field, in order to ensure the use of the necessary procedures for effective nursing practice. © 2018, Journal of Comprehensive Pediatrics.

Safe sleeping positions: practice and policy for babies with cleft palate

Guidance recommends ‘back to sleep’ positioning for infants from birth in order to reduce the risk of sudden infant death. Exceptions have been made for babies with severe respiratory difficulties where lateral positioning may be recommended, although uncertainty exists for other conditions affecting the upper airway structures, such as cleft palate. This paper presents research of (i) current advice on sleep positioning provided to parents of infants with cleft palate in the UK; and (ii) decision making by clinical nurse specialists when advising parents of infants with cleft palate. A qualitative descriptive study used data from a national survey with clinical nurse specialists from 12 regional cleft centres in the UK to investigate current practice. Data were collected using semi-structured telephone interviews and analysed using content analysis. Over half the regional centres used lateral sleep positioning based on clinical judgement of the infants’ respiratory effort and upper airway obstruction. Assessment relied upon clinical judgement augmented by a range of clinical indicators, such as measures of oxygen saturation, heart rate and respiration.Conclusion: Specialist practitioners face a clinical dilemma between adhering to standard ‘back to sleep’ guidance and responding to clinical assessment of respiratory effort for infants with cleft palate. In the absence of clear evidence, specialist centres rely on clinical judgement regarding respiratory problems to identify what they believe is the most appropriate sleeping position for infants with cleft palate. Further research is needed to determine the best sleep position for an infant with cleft palate.Whatis Known• Supine sleep positioning reduces the risk of sudden infant death in new born infants.• There is uncertainty about the benefits or risks of lateral sleep positioning for infants with upper airway restrictions arising from cleft palate.What is New• Variability exists in the information/advice provided to parents of infants with cleft palate regarding sleep positioning.• Over half the national specialist centres for cleft palate in the UK advise positioning infants with CP in the lateral position as a routine measure to reduce difficulties with respiration.

The clinical importance of obstructive sleep apnea in Alzheimers disease

Recent findings suggest that obstructive sleep apnea (OSA) is very common and underdiagnosed in the early stages of dementia and Alzheimer’s disease (AD). The objective of this study was to assess the prevalence and nightly variance in OSA in mild AD patients in relation to repeated assessments of cognitive function and neuropsychiatric symptoms. Twenty mild AD patients (mini-mental state examination [MMSE] >20; age 45–80 years), over a time period of four weeks, underwent a home type 3 sleep study including pulse oximetry, assessment of respiratory effort, airflow, body position and movement. CogState computerized cognitive assessments and the psychomotor vigilance test (PVT) were performed each morning following the sleep assessments to measure visual memory, attention/vigilance and working memory. Participants additionally completed the Epworth Sleepiness Scale and the Neuropsychiatric Inventory (NPI) was administered to their caregivers. The preliminary results showed an OSA prevalence of 90% (AHI¡Ý5) and an average (¡ÀSD) AHI of 13.0 (¡À5.7) events/hour over 5 assessments (12 patients had mild OSA, 3 moderate and 3 severe OSA). Substantial nightly fluctuations in OSA were seen with an average AHI fluctuation of 13.4 (¡À9.9) events/hour. Moreover, patients with an average AHI¡Ý10 ( n = 10 subjects) performed significantly worse on a test of visual attention/vigilance and presented with more apathy as a neuropsychiatric symptom than patients with an average AHI < 10 ( n = 10 subjects). However, no differences were found in other cognitive tests performed or in the PVT performance and only 5% of patients reported excessive daytime sleepiness (Epworth Sleepiness Scale ¡Ý10). OSA appears be underdiagnosed in AD and repeated assessments may lead to a more accurate diagnosis of OSA due to the nightly fluctuations in OSA severity. Preliminary findings suggest that cognition and neuropsychiatric symptoms in AD patients may be adversely affected by increased severity of OSA. Also, subjective reporting of sleepiness may not be suitable to screen for OSA in AD patients. Further studies are warranted to better understand the effects of OSA and its treatment on the clinical symptomatology of AD. Grant support from AstraZeneca.

Study on noninvasive assessment of respiratory effort in patients undergoing weaning from mechanical ventilation by mean inspiratory pressure

Objective To investigate the feasibility and efficiency of monitoring noninvasive respiratory effort and respiratory load-capacity ratio in patients undergoing weaning from mechanical ventilation by mean inspiratory pressure(Pi) which were calculated on the basis of the formula, Pi = 5 × P 0.1 × Ti, as well as the noninvasire tension index calculated from Pi(TTIi). Method Totally 12 patients undergoing weaning from mechanical ventilation were enrolled in the study and their underlying diseases included COPD( n = 9), ARDS( n = 2) and status asthmaticus(n = 1) respectively. Esophageal pressure(PesoM) was monitored via the insertion of esophageal balloon and corrected esophageal pressure(Peso) was acquired by subtracting elastic pressure of chest wall from PesoM. P 0.1, Maximal inspiratory pressure on esophageal pressure curve(MIPeso) and on airway pressure curve(MIPaw) was measured with conventional technique. Pi was calculated on Pi = 5 × P 0.1 × Ti. Pi and MIPaw were used to calculate the noninvasive tension-time index TTIi, whereas Peso and MIPeso were used to calculate the invasive counterpart TTIeso. Comparisons, Correlation and Bland-Altman agreement analysis were made between P0.1 and Peso as well as between TIIi and TTIeso. Results There were no significant differences between Pi and Peso as well as between TTIi and TTIeso(P > 0.05) ,and the correlation coefficients were 0.974 and 0.957 respectively. In the agreement analysis, the mean difference between Pi and Peso, and between TTIi and TTIeso were lower than the minimal values of(Peso + PiSB )/2 and of(TIIi + TTIeso)/2, respectively. Conclusions There is a good correlation between Pi and Peso as well as between TTIi and TTIeso, in which Pi is calculated calculated from P 0.1 and in turn the TTIi is calculated from Pi. The noninvasive indices including Pi and TTIi can be used to monitor respiratory effort and respiratory load-capacity in patients undergoing weaning from mechanical ventilation. Key words: Mean inspiratory pressure(Pi) ; Tension-time index(TTI) ; Respiratory effort; Noninvasive as-sessment; Weaning