NIV and Glottis-diaphragm Synchrony

Effect of Noninvasive Ventilation on the Synchrony of the Upper Airways and Inspiration.

Noninvasive ventilation (NIV) can provide ventilatory support in selected patients with acute respiratory failure, for instance due to acute exacerbation of COPD and acute heart failure. Advantages of noninvasive ventilation compared to invasive mechanical ventilation include absence of complications associated with endotracheal intubation, lower risk of pneumonia, lower level or even absence of sedation and the ability of the patient to verbally communicate. However, in approximately 30% of patients NIV fails and endotracheal intubation is needed to provide optimal ventilatory support. Surprisingly, very few studies have investigated why patients fail on NIV. Clinical observations indicated that agitation, delirium and most importantly asynchrony between patient and ventilator play a role in unsuccessful support with NIV. The upper airways are bypassed during endotracheal intubation. However, with NIV the upper airways may play a role in the efficiency of ventilatory support. In normal breathing the upper airways actively dilate before initiation of inspiratory flow. This is a highly appropriate response as it prevents narrowing of the upper airways during inspiration, which would result in elevated inspiratory resistance. Experiments in newborn lambs have shown that NIV has profound effects on physiology of the upper airways. Positive pressure during inspiration results in constriction of upper airway muscles in the early phase of inspiration. This results in elevated upper airway resistance with lower tidal volume delivered to the lungs. Subsequent studies revealed that reflexes that mediate this response originate in vagal afferences located in the lower airways. From an evolutionary point of view this might be an appropriate response, as high pressure delivered to the lungs may induce barotraumas. However, these responses may negatively affect the efficiency of ventilatory support delivered during NIV. The understanding of upper airway constriction and dilation during NIV is rudimentary. This study aims at determining the effect of NIV on regulation of upper airway patency in patients with COPD.

Study Overview

• Status: Unknown
• Conditions: Noninvasive Ventilation; NAVA Catheter; Hypercapnic Exacerbation COPD

• Study Type: Observational
• Enrollment (Anticipated): 10

Contacts and Locations

Study Locations

• Netherlands
  • Gelderland
    • Nijmegen, Gelderland, Netherlands, 6500HB
      • Recruiting
      • University Medical Centre Radboud
      • Contact: L Heunks, MD PhD; Phone Number: 0243617273; Email: l.heunks@ic.umcn.nl
      • Contact: E Oppersma, MSc; Phone Number: 0243617273; Email: e.oppersma@ic.umcn.nl
      • Principal Investigator: L Heunks, MD PhD

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

The patient population for this study will be included from the intensive care. All patients at the intensive care unit who are in clinical need of noninvasive mechanical ventilation due to hypercapnic COPD and with a NAVA catheter in situ, will be screened and asked for informed consent to participate.

Description

Inclusion Criteria:

• Informed consent
• COPD
• Hypercapnic respiratory acidosis
• Clinical need of NIV ventilation on the intensive care
• NAVA catheter in situ

Exclusion Criteria:

• Pre-existent muscle disease (congenital or acquired) or diseases / disorders known to be associated with myopathy including auto-immune diseases.
• Diabetes
• Upper airway/esophageal/mouth or face pathology (i.e. recent surgery, esophageal varices, diaphragmatic hernia)
• Recent (< 1 month) nasal bleeding
• Allergic to xylocaïne

Study Plan

How is the study designed?

Number of groups / cohorts

1

Cohorts and Interventions

Group / Cohort
COPD patients receiving NIV

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
The extent of glottis closure during diaphragm activation and the time delay in glottis opening with respect to diaphragm activity	1 Day

Collaborators and Investigators

• Sponsor: University Medical Center Nijmegen

Publications and helpful links

General Publications

• Oppersma E, Doorduin J, Roesthuis LH, van der Hoeven JG, Veltink PH, Heunks LM. Patient-Ventilator Interaction During Noninvasive Ventilation in Subjects With Exacerbation of COPD: Effect of Support Level and Ventilator Mode. Respir Care. 2020 Sep;65(9):1315-1322. doi: 10.4187/respcare.07159. Epub 2020 Mar 10.

Study record dates

Study Major Dates

• Study Start: October 1, 2012
• Primary Completion (Anticipated): January 1, 2016

Study Registration Dates

• First Submitted: February 12, 2013
• First Submitted That Met QC Criteria: February 12, 2013
• First Posted (Estimate): February 13, 2013

Study Record Updates

• Last Update Posted (Estimate): June 10, 2015
• Last Update Submitted That Met QC Criteria: June 9, 2015
• Last Verified: June 1, 2015

More Information

Terms related to this study

• Keywords: Noninvasive ventilation; Upper airway; Respiratory Muscles; Glottis
• Additional Relevant MeSH Terms: Signs and Symptoms, Respiratory; Hypercapnia
• Other Study ID Numbers: NIVGlottis