Nasal pressure swings as the measure of inspiratory effort in spontaneously breathing patients with de novo acute respiratory failure

Roberto Tonelli, Andrea Cortegiani, Alessandro Marchioni, Riccardo Fantini, Luca Tabbì, Ivana Castaniere, Emanuela Biagioni, Stefano Busani, Chiara Nani, Caterina Cerbone, Morgana Vermi, Filippo Gozzi, Giulia Bruzzi, Linda Manicardi, Maria Rosaria Pellegrino, Bianca Beghè, Massimo Girardis, Paolo Pelosi, Cesare Gregoretti, Lorenzo Ball, Enrico Clini, Roberto Tonelli, Andrea Cortegiani, Alessandro Marchioni, Riccardo Fantini, Luca Tabbì, Ivana Castaniere, Emanuela Biagioni, Stefano Busani, Chiara Nani, Caterina Cerbone, Morgana Vermi, Filippo Gozzi, Giulia Bruzzi, Linda Manicardi, Maria Rosaria Pellegrino, Bianca Beghè, Massimo Girardis, Paolo Pelosi, Cesare Gregoretti, Lorenzo Ball, Enrico Clini

Abstract

Background: Excessive inspiratory effort could translate into self-inflicted lung injury, thus worsening clinical outcomes of spontaneously breathing patients with acute respiratory failure (ARF). Although esophageal manometry is a reliable method to estimate the magnitude of inspiratory effort, procedural issues significantly limit its use in daily clinical practice. The aim of this study is to describe the correlation between esophageal pressure swings (ΔPes) and nasal (ΔPnos) as a potential measure of inspiratory effort in spontaneously breathing patients with de novo ARF.

Methods: From January 1, 2021, to September 1, 2021, 61 consecutive patients with ARF (83.6% related to COVID-19) admitted to the Respiratory Intensive Care Unit (RICU) of the University Hospital of Modena (Italy) and candidate to escalation of non-invasive respiratory support (NRS) were enrolled. Clinical features and tidal changes in esophageal and nasal pressure were recorded on admission and 24 h after starting NRS. Correlation between ΔPes and ΔPnos served as primary outcome. The effect of ΔPnos measurements on respiratory rate and ΔPes was also assessed.

Results: ΔPes and ΔPnos were strongly correlated at admission (R2 = 0.88, p < 0.001) and 24 h apart (R2 = 0.94, p < 0.001). The nasal plug insertion and the mouth closure required for ΔPnos measurement did not result in significant change of respiratory rate and ΔPes. The correlation between measures at 24 h remained significant even after splitting the study population according to the type of NRS (high-flow nasal cannulas [R2 = 0.79, p < 0.001] or non-invasive ventilation [R2 = 0.95, p < 0.001]).

Conclusions: In a cohort of patients with ARF, nasal pressure swings did not alter respiratory mechanics in the short term and were highly correlated with esophageal pressure swings during spontaneous tidal breathing. ΔPnos might warrant further investigation as a measure of inspiratory effort in patients with ARF.

Trial registration: NCT03826797 . Registered October 2016.

Keywords: Acute respiratory failure; COVID-19; Endotracheal intubation; Esophageal pressure swings; Inspiratory effort; Nasal pressure swings; Non-invasive Mechanical ventilation; Respiratory monitoring; Self-inflicted lung injury.

Conflict of interest statement

Authors have no competing interests with any organization or entity with a financial interest in competition with the subject, matter or materials discussed in the manuscript. Prof. Andrea Cortegiani is an Advisory Board member for Critical Care.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
A Simultaneous positioning of esophageal catheter for ΔPes assessment and nasal plug made of hypoallergenic foam ear plug equipped with a 16 Gauge polyurethane intravenous cannula for ΔPnos measurements. The contralateral nostril was kept open. B, C Simultaneous assessment of ΔPnos and ΔPes during unsupported spontaneous breathing, showing in phase waveforms with a 196 ms time latency of ΔPnos over the onset of inspiratory effort captured by ΔPes. D, E Simultaneous assessment of ΔPnos and ΔPes, showing decremental inspiratory effort after NIV placement
Fig. 2
Fig. 2
Pearson’s R showing correlation between ΔPes and ΔPnos at baseline (A), when all patients were assisted with HFNC (R2 = 0.88, p < 0.001), and at 24 h (B, R2 = 0.94, p < 0.001), with most patients receiving NIV. At both time points ΔPes and ΔPnos showed strong correlation
Fig. 3
Fig. 3
Histogram bars illustrating the distribution of ΔPes/ΔPnos ratio at baseline and at 24 h. The ratio was not different between baseline and 24 h (p = 0.41)

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