COPD Clinical Trial
Official title:
Changes in Lung Ventilation With Different Modes of Non-invasive Ventilation in COPD and OHS Patients
Patients with severe respiratory diseases such as chronic obstructive pulmonary disease
(COPD) or obesity-hypoventilation syndrome (OHS) can benefit from having non-invasive
ventilation (NIV). NIV consists of a machine (ventilator) that is blowing air inside a
patient's airway through a mask. NIV provides patients with a bigger breath. Bigger breaths
help patients to have a more oxygen and less waste gas (or carbon dioxide) in their body.
These changes can improve outcomes and quality of life. In order to provide appropriate
ventilation for each patient, the ventilator can generate different types of blowing:
- Continuous positive airway pressure (CPAP) which delivers a constant flow of air
through the mask
- Pressure support ventilation (PSV) which delivers a constant flow of air through the
mask and, on top of that, delivers more flow when the patient begins to inhale
- Volume targeted ventilation which delivers a flow of air through the mask that is
adjusted breath by breath in order to achieve a preset volume.
These different type of blowing have consequences on patient comfort as well as on the
improvement of their ventilation.
To assess the improvement of the ventilation, currently blood tests are used, however, these
reflect overall output and may miss more subtle changes in breathing that could affect how
patients feel.
Electrical impedance tomography (EIT) is a new technology that involves wearing a belt of
sensors around the chest that provides information on how well the lungs are being filled
with air by the ventilator. It allows a non-invasive assessment of the effect of NIV on lung
ventilation in real-time.
The investigators hope to use the EIT technology to assess in real-time patients lung
ventilation when they are using the NIV. The investigators hope that EIT will provide
information on which type of blowing is more effective and more comfortable than the others.
Chronic lung disease can sometimes progress to the extent that patients can no longer clear
the waste gas from their blood. Treatment can be offered with a mask and machine
(ventilator) that helps people breathe and aims to improve their lung condition. It is
common for people's lungs to be affected variably, i.e. left more than right or top of lung
more than bases of lungs. The way in which the ventilator is set may affect how well the
machine deals with these differences. If the lung is better ventilator patients may find the
machine more comfortable and it may be more effective.
Electrical impedance tomography (EIT) is a new technology that involves wearing a belt of
sensors around the chest that provides information on how well the lungs are being filled
with air by the ventilator. It allows the assessment of these differences, which previously
required the use of invasive equipment to obtain.
Optimising ventilator settings in the administration of non-invasive ventilation (NIV) can
be improved with the addition of individual physiological data. This approach is limited due
to the invasive techniques required to obtain this information, often leading to less ideal
NIV settings promoting patient-ventilator asynchrony. It has been recently demonstrated by
our group that all patients established on domiciliary NIV have a degree of
patient-ventilator asynchrony and that the commonest type of asynchrony are triggering
issues. Triggering asynchrony is promoted by mismatch between a patient's intrinsic positive
end-expiratory pressure (iPEEP) and applied expiratory positive airway pressure (EPAP) with
these ineffective efforts contributing to an increased work of breathing and patient
discomfort. Previous strategies used to optimise patient triggering have involved the
placement of oesophageal catheters in order to measure neural respiratory drive (NRD) to the
diaphragm by electromyography (EMG) but again this process is invasive and often poorly
tolerated. Electrical Impedance Tomography (EIT) is a non-invasive, bedside monitoring
technique that provides semi-continuous, real-time information about the regional
distribution of the changes in electrical resistivity of the lung tissue due to variations
in ventilation in relation to a reference state.
Information is gained by repeatedly injecting small alternating electric currents (usually 5
mA) at high frequency of 50 - 80 kHz through a system of skin electrodes (usually 16)
applied circumferentially around the thorax in a single plane between the 4th and 6th
intercostal space. While an adjacent pair of electrodes 'injects' the current ('adjacent
drive configuration'), all the remaining adjacent passive electrode pairs measure the
differences in electric potential. A resistivity (impedance) image is reconstructed from
this data by a mathematical algorithm using a two dimensional model and a simplified shape
to represent the thoracic cross-section.
The resulting image possesses a high temporal and functional resolution making it possible
to monitor dynamic physiological phenomena (e.g. delay in regional inflation or recruitment)
on a breath by breath basis. It is important to realize that the EIT images are based on
image reconstruction techniques that require at least one measurement on a well-defined
reference state. All quantitative data are related to this reference and can only indirectly
quantify (relative) changes in local lung impedance (but not absolute).
EIT can be used in mechanically ventilated patients to assess recruitment and to optimise
ventilator settings to reduce risk of iatrogenic ventilator associated lung injury.
In the supine posture obese patients can generate significant levels of iPEEP that
contribute to increased levels of neural respiratory drive compared with the upright
posture. There has been much debate regarding the optimal ventilator strategy in patients
with obesity related respiratory failure, with uncontrolled trial data to support simple
continuous positive airway pressure, pressure support (PSV) NIV and volume targeted (VT)
NIV. There has been no robust evidence to suggest superiority of a single mode but post hoc
data suggests superior control of sleep disordered breathing in patients in pressure
controlled mode. It is unclear whether the extended inspiratory time of pressure controlled
mode is allowing superior gas exchange by maintaining airway distension and preventing
regional collapse.
In COPD, patients' response to treatment can be influenced by disease heterogeneity with
some patients showing even distribution of lung damage and others marked differences
throughout the lungs. This variation can lead to significant differences in the lung
mechanics in different regions with optimal NIV settings for some regions having potentially
deleterious effects on neighbouring zones. It has been shown that control of hypoventilation
and improved blood gas exchange is essential in order to improve outcomes with NIV in COPD
but is less clear if pressure control ventilation as advocated by Windisch and colleagues is
required in order to achieve this effect. Inappropriate settings of NIV can also lead to
dynamic distension that results in a decrease of tidal volume and an increase in patient
discomfort.
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