Javier Sayas Catalán1, Ignacio Jiménez Huerta2, Pedro Benavides Mañas3, Manel Luján4, Daniel López-Padilla3,5, Eva Arias Arias3, Ana Hernández Voth3, Claudio Rabec6. 1. Servicio de Neumología, Hospital Universitario 12 de Octubre, Madrid, Spain. jsayascat@gmail.com. 2. Otorhinolaryngology Department, Servicio de Neumología, Hospital Universitario 12 de Octubre, Madrid, Spain. 3. Servicio de Neumología, Hospital Universitario 12 de Octubre, Madrid, Spain. 4. Servei de Pneumologia, Corporaciò Sanitària Parc Taulí, Hospital de Sabadell, Universitat Autònoma de Barcelona, Parc Taulí, Sabadell and CIBERES, Instituto de Salud Carlos III, Madrid, Spain. 5. Fundación para la Investigación Biomédica del Hospital General Universitario Gregorio Marañón, Madrid, Spain. 6. Service de Pneumologie et Soins Intensifs Respiratoire, Centre Hospitalier Universitaire de Dijon, Dijon, France.
Abstract
BACKGROUND: Noninvasive ventilation (NIV) titration may be difficult when dynamic airway obstruction episodes persist, even with high expiratory positive airway pressure (EPAP). We aimed to determine the usefulness of videolaryngoscopy during NIV for identifying mechanisms and sites of obstruction and for providing a guide for their resolution in difficult-to-titrate subjects. METHODS: When obstructions during NIV were present in the built-in software, EPAP was raised to 12 cm H2O. If obstructions persisted, a polygraphy during NIV was performed; if the events occurred with effort, a videolaryngoscopy with nasal and oronasal masks in awake subjects was performed. RESULTS: In a population of 208 subjects in whom NIV was initiated, 13 were identified as difficult to titrate with persistent obstructions during NIV despite an EPAP of 12 cm H2O. Videolaryngoscopy during NIV was able to identify the mechanism and the site of obstruction in all cases. The obstruction under oronasal mask ventilation was due to soft-palate (velum) collapse in 4 subjects, to epiglottic backward movement in 5 other subjects, and to tongue-base obstruction reducing the retroglossal space in 3 more. Videolaryngoscopy during NIV demonstrated improvement in 9 subjects (69%) upon changing to nasal mask and suggested a possible surgical approach in 2 (15%); in one of these 2 subjects, a successful uvulopalatopharyngoplasty was performed. CONCLUSIONS: The use of videolaryngoscopy during NIV in difficult-to-titrate patients may help to identify the sites and mechanisms of obstruction and in some cases may improve quality of ventilation.
BACKGROUND: Noninvasive ventilation (NIV) titration may be difficult when dynamic airway obstruction episodes persist, even with high expiratory positive airway pressure (EPAP). We aimed to determine the usefulness of videolaryngoscopy during NIV for identifying mechanisms and sites of obstruction and for providing a guide for their resolution in difficult-to-titrate subjects. METHODS: When obstructions during NIV were present in the built-in software, EPAP was raised to 12 cm H2O. If obstructions persisted, a polygraphy during NIV was performed; if the events occurred with effort, a videolaryngoscopy with nasal and oronasal masks in awake subjects was performed. RESULTS: In a population of 208 subjects in whom NIV was initiated, 13 were identified as difficult to titrate with persistent obstructions during NIV despite an EPAP of 12 cm H2O. Videolaryngoscopy during NIV was able to identify the mechanism and the site of obstruction in all cases. The obstruction under oronasal mask ventilation was due to soft-palate (velum) collapse in 4 subjects, to epiglottic backward movement in 5 other subjects, and to tongue-base obstruction reducing the retroglossal space in 3 more. Videolaryngoscopy during NIV demonstrated improvement in 9 subjects (69%) upon changing to nasal mask and suggested a possible surgical approach in 2 (15%); in one of these 2 subjects, a successful uvulopalatopharyngoplasty was performed. CONCLUSIONS: The use of videolaryngoscopy during NIV in difficult-to-titrate patients may help to identify the sites and mechanisms of obstruction and in some cases may improve quality of ventilation.
Authors: Anne Kristine Brekka; Maria Vollsæter; George Ntoumenopoulos; Hege Havstad Clemm; Thomas Halvorsen; Ola Drange Røksund; Tiina Maarit Andersen Journal: BMJ Open Date: 2022-05-25 Impact factor: 3.006