Changes in Ventilatory Muscle Function with Negative Pressure Ventilation in Patients with Severe COPD

doi:10.1378/chest.97.2.322

Chest

Volume 97, Issue 2, February 1990, Pages 322-327

https://doi.org/10.1378/chest.97.2.322 Get rights and content

Patients with severe COPD may be in a state of ventilatory muscle (VM) fatigue. In these patients, rapid and shallow breathing has been hypothesized to be a compensatory mechanism that prevents more severe fatigue from taking place. To test these hypotheses, we studied the effects of VM resting in a group of patients with severe COPD. Eleven clinically stable patients with COPD and chronic hypercapnia were studied. Six of them (group A) had a seven-day period of negative pressure-assisted ventilation (NPV), and five (group B) with similar functional characteristics served as a control group. Compared with a normal age-matched control group, both A and B groups exhibited significantly lower tidal volume (VT), inspiratory time (TI), total time of the respiratory cycle (Ttot) and TI/Ttot ratio, decrease in muscle strength, and greater electromyographic activity of diaphragm (EMGd) and parasternal muscles, but similar ventilation and VT/TI. After the study period, group A exhibited significant increase in VT, Ti, and TI/Ttot (p<0.05), and decrease in PaCO₂ (p<0.05), EMGd, and EMGint (p<0.05 for both), and a slight but significant increase in maximal inspiratory pressure (MIP) (p<0.05). These data suggest that NPV rests VM, increases their strength, and reduces hypercapnia in patients with severe COPD.

(Chest 1990; 97:322–27)

Section snippets

Subjects

Eleven hospitalized patients, nine men and two women, were studied after the nature of the experimental technique and the purpose of the investigation had been fully explained to them. Patients were defined as suffering from COPD according to the American Thoracic Society (ATS) criteria.¹⁵ All patients were free of active cardiovascular disease. An age-matched group of six normal subjects (mean±SD age, 62.0±8.7 years) was also included as a control.

Functional Evaluation

Routine spirometry obtained with subjects in a

RESULTS

Functional data of the three groups were summarized in Table 1. As shown, the study group (A) and the control group (B) exhibited similar VC, FRC, FEV₁, and FEV₁/VC ratio, MIP and MEP, and PaO₂, and PaCO₂; these values being significantly different compared with the mean value of the normal control group (C group). Breathing characteristics (Table 2) were also similar in groups A and B but, compared with group C, both groups A and B exhibited a significantly lower VT (p<0.01) and TI (p<0.01)

DISCUSSION

Our data show that in chronically stable hypercapnic patients with COPD, NPV reduces respiratory muscle activity (EMG), slightly increases muscle strength (MIP and MEP), and improves arterial blood gas values (PaO₂ and PaCO₂). These changes were coincident with significant increases in TI, VT, and TI/Ttot and a decrease in RF.

In patients with COPD, increase in airway resistance and lung hyperinflation enhance the energy demand of the respiratory muscles3, 4; furthermore, the hypoxemia reduces

ACKNOWLEDGMENTS

The writers wish to thank Drs. R. Ginanni and A. Fanelli for assisting in the preparation of this article.

REFERENCES (31)

CA Cohen et al.
Clinical manifestations of inspiratory muscle fatigue
Am J Med
(1982)
NMT Braun et al.
When should respiratory muscles be exercised?
Chest
(1983)
WA Whitelaw et al.
Occlusion pressure as a measure of respiratory center output in conscious man
Respir Physiol
(1975)
A Cropp et al.
Effects of intermittent negative pressure ventilation on respiratory muscle function in patients with severe chronic obstructive pulmonary disease
Am Rev Respir Dis
(1987)
C Roussos et al.
The respiratory muscles
N Engl J Med
(1982)
C Roussos
Ventilatory muscle fatigue governs breathing frequency
Bull Eur Physiopathol Respir
(1984)
DF Rochester et al.
Diaphragmatic energy expenditure in chronic respiratory failure: the effect of assisted ventilation with body respirators
Am J Med
(1977)
A Oliven et al.
Mechanisms underlying CO2 retention during flow-resistive loading in patients with COPD
J Clin Invest
(1983)
W Marino et al.
Reversal of the sequelae of respiratory muscle fatigue by intermittent mechanical ventilation [abstract]
Am Rev Respir Dis
(1982)
DO Rodenstein et al.
Ventilatory and diaphragmatic EMG changes during negative-pressure ventilation in healthy subjects
J Appl Physiol
(1988)

RD Levy et al.

Suppression of ventilatory muscle (VM) activity in COPD patients with negative pressure ventilation (NPV)

Am Rev Respir Dis

(1988)

M Gutierrez et al.

Weekly cuirass ventilation improves blood gases and inspiratory muscle strength in patients with chronic air-flow limitation and hypercarpnia

Am Rev Respir Dis

(1988)

M Gillen et al.

Diaphragmatic rest for eight hours improves diaphragmatic contractility in some normocapnic COPD patients [abstract]

Am Rev Respir Dis

(1987)

DO Rodenstein et al.

Ventilatory and diaphragmatic EMG responses to negative-pressure ventilation in airflow obstruction

J Appl Physiol

(1988)

ND Cooper et al.

Acute effects of external negative pressure ventilation in chronic obstructive pulmonary disease

Am Rev Respir Dis

(1988)

Cited by (49)

Variation in ventilatory response to CO<inf>2</inf> in patients treated by non-invasive ventilation
2021, Revue des Maladies Respiratoires
Les mécanismes d’amélioration clinique et gazométrique des patients mis sous ventilation non invasive (VNI) avec un syndrome obésité hypoventilation (SOH) ou une broncho-pneumopathie chronique obstructive (BPCO) sont multiples. L’objectif de ce travail a été de mettre en place une étude pilote permettant d’évaluer la modification potentielle de la sensibilité des centres respiratoires au CO₂ chez des patients BPCO et SOH nouvellement appareillés par VNI.
Nous avons évalué la sensibilité des centres respiratoires au CO₂ par le test de Read chez 3 patients BPCO et 3 patients SOH nouvellement appareillés par VNI puis à 3 mois. Nous avons comparé leurs résultats à ceux de 6 sujets contrôles.
Tous les patients inclus avaient des réponses ventilatoires au CO₂ altérées avec des pentes inférieures à 1 L.min⁻¹.mmHg⁻¹. Le coefficient de variation moyen des deux mesures était significativement plus élevé chez les patients que chez les sujets sains (p = 0,007). Les patients améliorant leur pente de sensibilité au CO₂ étaient les plus observants pour la VNI.
Ce travail a mis en évidence des variations significatives de la réponse ventilatoire à l’hypercapnie chez les patients SOH ou BPCO après traitement par VNI. La signification de ces variations mérite d’être étudiée.
There are many mechanisms for improving the clinical and blood gas status of patients with the obesity hypoventilation syndrome (OHS) or chronic obstructive pulmonary disease (COPD) by non-invasive ventilation (NIV) at home. Our objective was to set up a pilot study to evaluate the potential modification of the sensitivity of the respiratory centers to CO₂ by NIV in paired new COPD and OHS patients.
We assessed the sensitivity of the respiratory centers to CO₂ by the Read method in 3 COPD patients and 3 OHS patients newly treated by NIV and again 3 months later. We compared their results to those of 6 control subjects.
All the patients included had altered ventilatory responses to CO₂ with slopes of less of than 1 L.min^-1.mmHg^-1. Mean coefficients of variation were significantly higher in patients than in healthy subjects (P = 0.007). Patients who improved their CO₂ sensitivity slope were those most observant of NIV.
This work showed significant changes in the ventilatory response to hypercapnia in patients with either OHS or COPD after NIV therapy. The significance of these changes deserves to be studied.
Domiciliary ventilation in patients with COPD
2005, Revue des Maladies Respiratoires
La bronchopneumopathie chronique obstructive (BPCO) est un motif croissant d’indication à la ventilation à domicile (VAD) souvent par une ventilation non invasive (VNI). Cette revue générale a pour objectif de détailler les éléments physiopathologiques et les résultats des études cliniques qui étayent aujourd’hui les recommandations des sociétés savantes internationales.
Les études publiées ne sont pas toujours contrôlées, sont souvent de trop courte durée ou grevées d’aléas méthodologiques importants. Les deux études contrôlées et de durée ≥ 12 mois sont concordantes pour suggérer que la VNI n’améliore pas la survie. En conséquence, une VAD peut être envisagée en situation d’échec de l’oxygénothérapie de longue durée, dans un contexte d’aggravation progressive de l’état clinique et respiratoire et la survenue de fréquents épisodes d’insuffisance respiratoire aiguë hypercapnique. La présence d’une hypercapnie diurne ≥ 55 mmHg (7,3 kPa) est une condition nécessaire mais non suffisante pour indiquer ce traitement.
La VAD ne doit être envisagée que chez des patients sélectionnés, pour lesquels la symptomatologie clinique et la fréquence des exacerbations doivent être pris en compte. Dans l’attente d’une caractérisation des patients répondeurs, une ré-évaluation régulière du traitement est nécessaire au décours.
Chronic obstructive pulmonary disease (COPD) has become one of the main indications for domiciliary ventilation, which is usually non-invasive (NIV). This review focuses on the pathophysiology processes and clinical trial data that underlie current guidelines from international societies.
To date most published studies about domiciliary ventilation in COPD have been short-term and their message is complicated by the presence of significant methodological problems. The two controlled studies of ≥ 12 months-duration both found that survival was not improved by long-term NIV. Domiciliary ventilation may be considered when long-term oxygen therapy is unsuccessful and when failed with a progressive deterioration in clinical respiratory status with recurrent episodes of acute hypercapnic respiratory failure. A diurnal PaCO2 ≥ 55 mmHg (7.3 kPa) is a necessary but not sufficient condition to consider domiciliary ventilation.
Domiciliary ventilation should only be initiated in selected patients on the basis of clinical symptoms and exacerbation frequency. Until further characterization of patients who are likely to respond, the response to treatment should be assessed regularly.
A meta-analysis of nocturnal noninvasive positive pressure ventilation in patients with stable COPD
2003, Chest
Citation Excerpt :
Celli et al37 and Zibrak et al38 also failed to identify improvements in ABG levels or respiratory muscle strength with NPV. As with NIPPV, these studies with negative findings included patients with a mean Paco2 of 45 mm Hg, whereas the studies with positive findings included patients with higher Paco2 levels.394041 Neither studies on NPV or NIPPV have clarified whether, in the few patients who did improve, the benefits related to improvements in respiratory muscle function or in gas exchange.35
The potential benefits of noninvasive positive pressure ventilation (NIPPV) for patients with COPD remains inconclusive, as most studies have included only a small number of patients. We therefore undertook a meta-analysis of randomized controlled trials (RCTs) that compared nocturnal NIPPV with conventional management in patients with COPD and stable respiratory failure.
RCTs were identified from several sources, such as MEDLINE, EMBASE, and CINAHL. In addition, records were identified through hand searching of abstracts from meetings of the American Thoracic Society, the American College of Chest Physicians, and the European Respiratory Society.
Patients with COPD according to the definition of the American Thoracic Society.
NIPPV applied via a nasal or facemask for at least 5 h/d for at least 3 weeks. Patients in the actively treated group continued to receive the usual management for COPD. The control group received the same management as the study group but did not receive NIPPV.
Paco₂, Pao₂, 6-min walking distance (6MWD), respiratory muscle function, FEV₁, vital capacity, and sleep efficiency (time asleep as a percentage of total time in bed) were used as outcome measures. The publications were reduced to 10 potentially eligible articles from 164 publications retrieved from computer searches and 8 further abstracts. Four trials were finally included in the meta-analysis. The only outcome for which the confidence intervals excluded zero was maximal inspiratory pressure (Pimax). The confidence intervals for the other outcomes included zero. The mean treatment effects for FEV₁ and Pimax were small, whereas it was moderate for the 6MWD. Small negative effects were found for the outcomes of vital capacity, Paco₂, and sleep efficiency.
This meta-analysis of 3 months of NIPPV in patients with stable COPD showed that ventilatory support did not improve lung function, gas exchange, or sleep efficiency. The high upper limit of the confidence interval for the 6MWD suggested that some people do improve their walking distance. The small overall sample size precluded a clear clinical direction regarding the effects of NIPPV in patients with COPD.
Management of dyspnea in severe chronic obstructive pulmonary disease
2000, Journal of Pain and Symptom Management
Progression of chronic obstructive pulmonary disease (COPD) is frequently associated with increasing dyspnea; indeed, patients with severe COPD constitute the largest group of patients with chronic respiratory insufficiency. The sensation of dyspnea in these patients is mostly related to increased work of breathing, a consequence of an increased resistive load, of hyperinflation, and of the deleterious effect of intrinsic positive end-expiratory pressure (PEEP_i). Once optimal medical treatment has been provided, pharmacological treatments of dyspnea exist (β2-agonists, methylxanthines, opiates) but seldom suffice. Nonpharmacological complementary treatments must be envisioned. Patients with severe hyperinflation should be screened as possible candidates for lung reduction surgery. Pulmonary rehabilitation—including chest therapy, patient education, exercise training—has been established as effective on quality of life (QoL) and dyspnea. Noninvasive positive pressure devices may be effective for symptomatic treatment of severe dyspnea: continuous positive airway pressure (CPAP) counteracts the deleterious effect of PEEP_i in patients with severe hyperinflation; intermittent positive pressure breathing (IPPB) may decrease dyspnea and discomfort during nebulized therapy; finally noninvasive positive pressure ventilation (NIPPV) has been shown to be effective on the sensation of dyspnea and QoL in COPD with severe hypercapnia.
Noninvasive ventilation in chronic obstructive pulmonary disease
2000, Clinics in Chest Medicine
Citation Excerpt :
The studies stimulated considerable interest, however, and a number of controlled trials followed soon thereafter. Several1,58,59 yielded favorable findings similar to those reported by Braun and Marino (Table 2). In each case, maximal inspiratory and expiratory pressures improved, consistent with the muscle resting hypothesis.
Noninvasive ventilation, referring to the provision of mechanical ventilatory assistance without the need for an invasive airway, has been assuming increasing importance in the management of chronic obstructive pulmonary disease (COPD). Particularly in the acute arena, where a number of randomized, controlled trials have demonstrated the efficacy of noninvasive positive-pressure ventilation (NPPV) in averting the need for intubation, noninvasive ventilation is now seen as the first choice mode of ventilation for the therapy of selected patients suffering from COPD exacerbations. Despite numerous studies spanning decades using different types of nonivasive ventilators and all manner of ventilator regimens, however, the use of noninvasive ventilation for patients with severe stable COPD remains controversial. The following discussion focuses on the use of noninvasive ventilation for patients with severe COPD in the subacute and stable settings, paying little attention to the acute setting. For more information on acute applications, the reader is referred elsewhere.2, 29 The following discussion includes the physiologic bases for the use of noninvasive ventilation in severe COPD, evidence for (or against) efficacy, possible indications and selection guidelines, newer possible uses, and practical application as it applies to patients with COPD.
Survival of individuals receiving long-term mechanical ventilation
2002, Respiratory Care Clinics of North America

View all citing articles on Scopus

This research was supported by grants from the Ministero della Pubblica Istruzione of Italy.

Manuscript received April 6; revision accepted July 14.

View full text

Chest

Changes in Ventilatory Muscle Function with Negative Pressure Ventilation in Patients with Severe COPD

Section snippets

Subjects

Functional Evaluation

RESULTS

DISCUSSION

ACKNOWLEDGMENTS

Am J Med

Chest

Respir Physiol

Effects of intermittent negative pressure ventilation on respiratory muscle function in patients with severe chronic obstructive pulmonary disease

Am Rev Respir Dis

The respiratory muscles

N Engl J Med

Ventilatory muscle fatigue governs breathing frequency

Bull Eur Physiopathol Respir

Diaphragmatic energy expenditure in chronic respiratory failure: the effect of assisted ventilation with body respirators

Am J Med

Mechanisms underlying CO2 retention during flow-resistive loading in patients with COPD

J Clin Invest

Reversal of the sequelae of respiratory muscle fatigue by intermittent mechanical ventilation [abstract]

Am Rev Respir Dis

Ventilatory and diaphragmatic EMG changes during negative-pressure ventilation in healthy subjects

J Appl Physiol

Suppression of ventilatory muscle (VM) activity in COPD patients with negative pressure ventilation (NPV)

Am Rev Respir Dis

Weekly cuirass ventilation improves blood gases and inspiratory muscle strength in patients with chronic air-flow limitation and hypercarpnia

Am Rev Respir Dis

Diaphragmatic rest for eight hours improves diaphragmatic contractility in some normocapnic COPD patients [abstract]

Am Rev Respir Dis

Ventilatory and diaphragmatic EMG responses to negative-pressure ventilation in airflow obstruction

J Appl Physiol

Acute effects of external negative pressure ventilation in chronic obstructive pulmonary disease

Am Rev Respir Dis