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Published on: September 8, 2023
Upper airway obstruction induced by non-invasive ventilation using an oronasal interface
Valentin Schellhas1, Christian Glatz1, Ingo Beecken1
1Department of Sleep Medicine and Neuromuscular Disorders, Münster University Hospital, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
Treatment-induced upper airway obstruction (TAO) can occur when starting non-invasive ventilation (NIV), especially in patients with neuromuscular disease. Careful adjustment of ventilator settings, including expiratory positive airway pressure (EPAP) and inspiratory-expiratory pressure interval (ΔPAP), is crucial to mitigate this risk.
Area of Science:
- Respiratory Medicine
- Sleep Medicine
- Neurology
Background:
- Non-invasive ventilation (NIV) is a critical treatment for respiratory insufficiency.
- Intermittent upper airway obstruction (UAO) during NIV is a rarely described, potentially treatment-induced complication.
- Patients with neuromuscular disease (NMD), particularly amyotrophic lateral sclerosis (ALS), may be susceptible to UAO due to NIV's inspiratory pressure effects and oronasal interface.
Purpose of the Study:
- To investigate the prevalence and characteristics of treatment-induced upper airway obstruction (TAO) in patients initiating long-term NIV.
- To identify potential contributing factors to TAO, including ventilator settings and patient characteristics.
Main Methods:
- A retrospective analysis of clinical data from 212 patients initiating NIV with an oronasal mask.
- TAO was defined as an apnea-hypopnea index (AHI) > 5/h with a relative increase in AHI on the first NIV night compared to diagnostic sleep studies.
- Correlation and prediction analyses were performed on ventilator settings (EPAP, ΔPAP) and patient subgroups (NMD, ALS).
Main Results:
- TAO prevalence was 14.2% overall, with higher rates in NMD (17.0%) and ALS (20.4%) subgroups compared to non-NMD patients (4.3%).
- Fixed expiratory positive airway pressure (EPAP) correlated significantly with AHI reduction (r=0.50, p<0.001).
- The inspiratory-expiratory pressure interval (ΔPAP) showed an inverse correlation with AHI change on the first night (r=-0.28, p<0.001), but neither ΔPAP nor the pressure range predicted TAO.
Conclusions:
- Initiation of NIV with an oronasal interface is associated with TAO in a subset of patients.
- Both EPAP and ΔPAP appear to play a role in the development of TAO.
- Careful titration of NIV settings is recommended to minimize the risk of TAO.
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