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Chest Physiotherapy in Cystic Fibrosis: Improved Tolerance with Nasal Pressure Support Ventilation

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Chest Physiotherapy in Cystic Fibrosis: Improved Tolerance with Nasal Pressure Support Ventilation Chest Physiotherapy in Cystic Fibrosis: Improved Tolerance With Nasal Pressure Support Ventilation Brigitte Fauroux, MD*; Miche`le Boule´, MD, PhD‡; Fre´de´ric Lofaso, MD, PhD§; Franc¸oise Ze´rah, MD§; Annick Cle´ment, MD, PhD*; Alain Harf, MD, PhD§; and Daniel Isabey, PhD§ ABSTRACT. Objective. Chest physiotherapy (CPT) is pared with the control session. SpO2 decreases after FET an integral part of the treatment of patients with cystic were significantly larger during the control session (na- fibrosis (CF). CPT imposes additional respiratory work dir: 91.8 6 0.7%) than during the PSV session (93.8 6 that may carry a risk of respiratory muscle fatigue. In- 0.6%). Maximal pressures decreased during the control 6 6 spiratory pressure support ventilation (PSV) is a new session (from 71.9 6.1 to 60.9 5.3 cmH2O, and from 6 6 mode of ventilatory assistance designed to maintain a 85.3 7.9 to 77.5 4.8 cmH2O, for PImax and PEmax, constant preset positive airway pressure during sponta- respectively) and increased during the PSV session (from 6 6 6 neous inspiration with the goal of decreasing the pa- 71.6 8.6 to 83.9 8.7 cmH2O, and from 80.4 7.8 to 88.0 6 tient’s inspiratory work. The aim of our study was 1) to 7.4 cmH2O, for PImax and PEmax, respectively). The evaluate respiratory muscle fatigue and oxygen desatu- decrease in PEmax was significantly correlated with the ration during CPT and 2) to determine whether noninva- severity of bronchial obstruction as evaluated based on sive PSV can relieve these potential adverse effects of baseline FEV1 (% predicted). Forced expiratory flows did CPT. not change after either CPT session. The amount of spu- Methods. Sixteen CF patients in stable condition with tum expectorated was similar for the two CPT sessions 6 a mean age of 13 4 years participated to the study. For (5.3 6 5.3 g vs 4.6 6 4.8 g after the control and PSV CPT, we used the forced expiratory technique (FET), session, respectively; NS). Fifteen patients felt less tired which consisted of one or more slow active expirations after the PSV session. Ten patients reported that expec- starting near the total lung capacity (TLC) and ending toration was easier with PSV, whereas 4 did not note any near the residual volume. After each expiration, the child difference; 2 patients did not expectorate. Nine patients was asked to perform a slow, nonmaximal, diaphrag- expressed a marked and 5 a small preference for PSV, matic inspiration. After one to four forced breathing cy- and 2 patients had no preference. The physiotherapists cles, the child was asked to cough and to expectorate. A found it easier to perform CPT with PSV in 14 patients typical 20-minute CPT session consisted of 10 to 15 FET and did not perceive any difference in 2 patients. maneuvers separated by rest periods of 10 to 20 breathing Discussion. Our study in CF children shows that cycles each. During the study, each patient received two respiratory muscle performance, as evaluated based on CPT sessions in random order on two different days, at various parameters, decreased after CPT and that sig- the same time of day, with the same physiotherapist. nificant falls in oxygen saturation occurred after the During one of these two sessions, PSV was provided FET maneuvers despite the quiet breathing periods throughout the session (PSV session) via a nasal mask between each FET cycle. These unwanted effects of using the pressure support generator ARM25 designed CPT were both reduced by noninvasive PSV delivered for acute patients (TAEMA, Antony, France). The control via a nasal mask. These data suggest that noninvasive session was performed with no nasal mask or PSV. Both PSV in CF patients partly compensated for the addi- CPT sessions were performed without supplemental ox- tional inspiratory overload resulting from FET, thereby ygen. Lung function and maximal inspiratory pressures decreasing the inspiratory work of breathing. This may (PImax) and expiratory pressures (PEmax) were recorded allow the patient, assisted by a physiotherapist, to before and after each CPT session. concentrate on the expiratory effort, which is the key to Results. Mean lung function parameters were compa- the efficacy of FET. rable before the PSV and the control sessions. Baseline In our study, PImax and PEmax decreased significantly pulse oximetry (SpO2) was significantly correlated with the baseline vital capacity (% predicted) and forced ex- after the control session, indicating that CPT was associ- ated with respiratory muscle fatigue. PImax improved piratory volume in 1 second (FEV1) (% predicted). PSV was associated with an increase in tidal volume (Vt) from significantly after the PSV session. PSV delivers an un- 0.42 6 0.01 liters to 1.0 6 0.02 liters. Respiratory rate was changing level of positive pressure during spontaneous inspiration, acting as an additional external inspiratory significantly lower during PSV. SpO2 between the FET maneuvers was significantly higher during PSV as com- muscle that reduces both the effort of breathing and the cost in oxygen in proportion to the level of pressure used. PSV has been shown to reduce diaphragmatic activity From the *Service de Pneumologie Pe´diatrique et ‡Service de Physiologie- and to prevent diaphragmatic fatigue in chronic obstruc- Explorations Fonctionnelles, Hoˆpital Armand Trousseau, Paris, France; and tive pulmonary disease patients. The improvement in the §Service de Physiologie-Explorations Fonctionnelles and Institut Na- PImax after the PSV session in our study suggests that tional de la Sante´et de la Recherche Me´dicale (INSERM) Unite´492, Hoˆpital PSV may “rest” the inspiratory muscles during CPT. The Henri Mondor, Cre´teil, France. improvement in PEmax after the PSV session could be Received for publication Jul 6, 1998; accepted Oct 19, 1998. Reprint requests to (B.F.) Service de Pneumologie Pe´diatrique, 28 avenue du explained by the increase in Vt during PSV. During PSV, Docteur Arnold Netter, 75571 Paris, France. the Vt tends to the TLC. This allows a larger amount of PEDIATRICS (ISSN 0031 4005). Copyright © 1999 by the American Acad- energy to accumulate, thereby facilitating expiration and emy of Pediatrics. decreasing the work of the expiratory muscles. http://www.pediatrics.org/cgi/content/full/103/3/Downloaded from www.aappublications.org/newse32 by PEDIATRICSguest on September Vol. 30,103 2021 No. 3 March 1999 1of9 The beneficial effect of PSV on SpO2 can be explained maintain a constant preset positive airway pressure by the large Vts, which can improve ventilation-perfu- during spontaneous inspiration with the goal of de- sion mismatching. creasing the patient’s inspiratory work. When the Conclusions. Our study is the first to show that PSV respiratory rate (RR), tidal volume (Vt), and inspira- performed with a nasal mask during the CPT was asso- tory time are controlled by the patient, the work ciated with an improvement in respiratory muscle per- performed by the inspiratory muscles, especially the formance and with a reduction in oxygen desaturation. diaphragm, has been shown to be substantially re- The improvement in patient comfort may help to im- 8 prove compliance with CPT in CF patients. Pediatrics duced. This method of partial mechanical ventila- 1999;103(3). URL: http://www.pediatrics.org/cgi/content/ tory support delivered via a face mask to patients full/103/3/e32; respiratory muscles, lung function, children, with acute exacerbations of chronic obstructive pul- cystic fibrosis, oxygenation, inspiratory assistance by pos- monary disease (COPD) has been found to obviate itive airway pressure, mucus. the need for conventional mechanical ventilation.9 One of the primary advantages of PSV is its good ABBREVIATIONS. CPT, chest physiotherapy; CF, cystic fibrosis; acceptability because of the fact that the frequency FET, forced expiratory technique; PSV, pressure support ventila- and duration of the inspiratory assistance are con- 8 tion; Spo2, pulse oximetry; FEV1, forced expiratory volume in 1 trolled by the patient rather than by the machine. second; TLC, total lung capacity; RR, respiratory rate; PETCo2, We studied children with CF 1) to evaluate respi- end-tidal Co2; mSpo2, mean Spo2; Vt, tidal volume; COPD, chronic ratory muscle fatigue and oxygen desaturation dur- obstructive pulmonary disease; VC, vital capacity; PEF, peak ex- piratory flow; FEF, forced expiratory flow; HR, heart rate; bpm, ing CPT, and 2) to determine whether noninvasive beats per minute; FRC, functional residual capacity; Pimax, max- PSV can relieve these potential adverse effects of imal inspiratory pressure; Pemax, maximal expiratory pressure; CPT. ANOVA, analysis of variance; RMS, respiratory muscle strength; LS, leg strength; CPAP, continuous positive airway pressure; METHODS BiPAP, bilevel positive pressure. The study protocol was approved by our institutional review board. Informed consent was given by all the patients and their hest physiotherapy (CPT) is an integral part of parents. the treatment of patients with cystic fibrosis Patients (CF). The goal of CPT is to improve ventila- C Sixteen clinically stable patients with CF (9 girls, 7 boys) with a tion and mucociliary clearance through the removal mean age of 13 6 4 years (range, 6 to 18 years) were studied. The of tenacious secretions obstructing the airways. The patients had to be in at baseline status, in a clinically stable phase removal of these secretions may relieve atelectasis of their disease. The mean Shwachmann score10 was 68 6 4 (range, and also may prevent or slow proteolytic airway 45 to 90). Nine patients were colonized with Pseudomonas aerugi- damage by clearing substances that can promote in- nosa and 7 with Burkholderia cepacia. Inhaled bronchodilators and 1 corticosteroids were used on a long-term basis by 6 and 7 patients, fection. Although CPT is considered an effective respectively.
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