Bi-level Positive Airway Pressure (BiPAP) with Standard Exhalation Valve Does Not Improve Maximum Exercise Capacity in Patients with COPD

Moga, A; Marchie, Michel de; Saey, Didier; Spahija, Jadranka

doi:10.3109/15412555.2014.908830

Cited by 5 publications

(11 citation statements)

References 38 publications

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“…Nonetheless, information regarding the effect of NIMV on maximum exercise workload (WLmax) is limited. Moga et al (18) reported a decrease in WLmax with the application of Bi-level positive airway pressure (BiPAP) during exercise, and concluded that the BiPAP's single limb tubing for inspiration and expiration resulted in carbon dioxide (CO 2 ) rebreathing and contributed to the reduction in WLmax. The occurrence of CO 2 rebreathing with BiPAP has been reported in both laboratory (19,20) and clinical (19,21) studies.…”

Section: Introductionmentioning

confidence: 99%

Effects of Pressure Support Ventilation May Be Lost at High Exercise Intensities in People with COPD

Anekwe

Marchie

Spahija

2017

COPD: Journal of Chronic Obstructive Pulmonary Disease

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Pressure support ventilation (PSV) may be used for exercise training in chronic obstructive pulmonary disease (COPD), but its acute effect on maximum exercise capacity is not fully known. The objective of this study was to evaluate the effect of 10 cm HO PSV and a fixed PSV level titrated to patient comfort at rest on maximum exercise workload (WLmax), breathing pattern and metabolic parameters during a symptom-limited incremental bicycle test in individuals with COPD. Eleven individuals with COPD (forced expiratory volume in one second: 49 ± 16%; age: 64 ± 7 years) performed three exercise tests: without a ventilator, with 10 cm HO of PSV and with a fixed level titrated to comfort at rest, using a SERVO-i ventilator. Tests were performed in randomized order and at least 48 hours apart. The WLmax, breathing pattern, metabolic parameters, and mouth pressure (Pmo) were compared using repeated measures analysis of variance. Mean PSV during titration was 8.2 ± 4.5 cm HO. There was no difference in the WLmax achieved during the three tests. At rest, PSV increased the tidal volume, minute ventilation, and mean inspiratory flow with a lower end-tidal CO; this was not sustained at peak exercise. Pmo decreased progressively (decreased unloading) with PSV at workloads close to peak, suggesting the ventilator was unable to keep up with the increased ventilatory demand at high workloads. In conclusion, with a Servo-i ventilator, 10 cm HO of PSV and a fixed level of PSV established by titration to comfort at rest, is ineffective for the purpose of achieving higher exercise workloads as the acute physiological effects may not be sustained at peak exercise.

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Section: Introductionmentioning

confidence: 99%

Effects of Pressure Support Ventilation May Be Lost at High Exercise Intensities in People with COPD

Anekwe

Marchie

Spahija

2017

COPD: Journal of Chronic Obstructive Pulmonary Disease

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“…In previous studies, investigating the effects of a single-limb circuit with a Silentflow Exhalation valve (Weinmann, Hamburg, Germany) to deliver ventilatory assistance (IPAP: 29.5±4.1 cmH 2 O, EPAP: 4.38±0.82 cmH 2 O) during exercise in COPD with hypercapnia,16,17 there were controversial outcomes on the alleviation of dyspnea. Moreover, in studies by Moga et al19 and Highcock et al,20 they found that BiPAP with Whisper Swivel II did not improve exercise capacity. These findings, in combination with the result found by Ferguson and Gilmartin21 that significant CO 2 rebreathing could occur at low expiratory pressure levels (≤4 cmH 2 O) on single-limb circuit with Whisper Swivel Valve or other fixed-resistance exhalation devices, suggested that CO 2 may not be adequately cleared with the fixed-resistance exhalation valve both at rest and during exercise and that this blunted the efficacy of NIV.…”

Section: Discussionmentioning

confidence: 93%

“…In these studies, one of the obvious methodological issues existed with respect to the selection of exhalation valve connected to the single-limb circuit. Evidence from Moga et al19 and Highcock et al20 indicated that NIV with a single-limb circuit with Whisper Swivel II expiratory valve (Respironics Inc., Murrysville, PA, USA) assisting exercise did not improve exercise capacity in COPD patients. Also, as previously reported by Ferguson and Gilmartin,21 the use of Whisper Swivel II expiratory valve during bi-level positive airway pressure (BiPAP) ventilatory assistance causes CO 2 rebreathing, which can blunt any effect of BiPAP on partial pressure of CO 2 (PaCO 2 ).…”

Section: Introductionmentioning

confidence: 99%

Evaluation of carbon dioxide rebreathing during exercise assisted by noninvasive ventilation with plateau exhalation valve

Lin

Hua

et al. 2017

COPD

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Noninvasive ventilation with a plateau exhalation valve (PEV) is often used as an adjunct to exercise to achieve a physiologic training effect in severe chronic obstructive pulmonary disease (COPD) patients. However, during exercise, with the increase of exhalation flow and respiratory rate and limited capability of PEV to exhale gases out of the circuit, it is still unknown whether CO2 rebreathing occurs in COPD patients ventilated during exercise assisted by single-limb circuit with a PEV. A maximal symptom-limited cycle exercise test was performed while ventilated on pressure support (inspiratory:expiratory pressure 14:4 cmH2O) in 18 male patients with stable severe COPD (mean ± standard deviation, forced expiratory volume in 1 s: 29.5%±6.9% predicted). At rest and during exercise, breathing pattern, mean expiratory flow, mean expiratory flow of PEV, and the mean inspiratory fraction of CO2 (tidal fractional concentration of inspired CO2 [FiCO2]) reinsufflated from the circuit was measured for each breath. In comparison with rest, with the significant increase of mean expiratory flow (0.39±0.15 vs 0.82±0.27 L/s), fractional concentration of end-tidal CO2 (2.6%±0.7% vs 5.5%±0.6%), and the significant decrease of mean expiratory flow of PEV (0.41±0.02 vs 0.39±0.03 L/s), tidal FiCO2 significantly increased at peak exercise (0.48%±0.19% vs 1.8%±0.6%) in patients with stable severe COPD. The inflection point of obvious CO2 rebreathing was 0.67±0.09 L/s (95% confidence interval 0.60–0.73 L/s). Ventilated by a single-limb tubing with PEV caused CO2 rebreathing to COPD patients during exercise. Patients with mean expiratory flow >0.60–0.73 L/s may be predisposed to a higher risk of CO2 rebreathing.

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“…Because of its complexity and the many parameters influencing its use, NIV during exercise is a much-debated topic with divergent results, particularly when used over a course of PR. Indeed, previous acute and physiological studies has mostly demonstrated a significant positive effect of NIV on exercise capacity [11,12,[28][29][30] or no positive effects [31,32], while long-term studies remain inconclusive [7,18,33]. In this context, the detrimental effect of NIV on endurance exercise capacity found in the present study was quite unexpected and it is therefore difficult to differentiate between a real worsening in endurance exercise capacity or a lack of improvement (there is also a possibility of a type 1 statistical error).…”

Section: Discussionmentioning

confidence: 99%

“…Additionally, other factors such as the low pressure support used [3,4], NIV-induced hypercapnia [31,35] or the patient's selection (i.e., without chronic hypercapnic respiratory failure (CHRF)) may also explain the lack of improvement in Tlim. Indeed, higher inspiratory support may have led to a positive effect of NIV as suggested by Gloeckl et al who found a significant improvement in endurance capacity with high-pressure NIV during exercise in patients already undergoing long-term NIV for CHRF [36].…”

Section: Discussionmentioning

confidence: 99%

NIV Is not Adequate for High Intensity Endurance Exercise in COPD

Bonnevie

Gravier

Fresnel³

et al. 2020

JCM

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Noninvasive ventilation (NIV) during exercise has been suggested to sustain higher training intensity but the type of NIV interface, patient-ventilator asynchronies (PVA) or technological limitation of the ventilator may interfere with exercise. We assessed whether these parameters affect endurance exercise capacity in severe COPD patients. In total, 21 patients with severe COPD not eligible to home NIV performed three constant workload tests. The first test was carried out on spontaneous breathing (SB) and the following ones with NIV and a nasal or oronasal mask in a randomized order. PVA and indicators of ventilator performance were assessed through a comprehensive analysis of the flow pressure tracing raw data from the ventilator. The time limit was significantly reduced with both masks (406 s (197–666), 240 s (131–385) and 189 s (115–545), p < 0.01 for tests in SB, with oronasal and nasal mask, respectively). There were few PVA with an oronasal mask (median: 3.4% (1.7–5.2)) but the ventilator reached its maximal generating capacity (median flowmax: 208.0 L/s (189.5–224.8) while inspiratory pressure dropped throughout exercise (from 10.1 (9.4–11.4) to 8.8 cmH2O (8.6–10.8), p < 0.01). PVA were more frequent with nasal mask (median: 12.8% (3.2–31.6), p < 0.01). Particularly, the proportion of patients with ineffective efforts > 10% was significantly higher with nasal interface (0% versus 33.3%, p < 0.01). NIV did not effectively improve endurance capacity in COPD patients not acclimated to home NIV. This was due to a technological limitation of the ventilator for the oronasal mask and the consequence either of an insufficient pressure support or a technological limitation for the nasal mask.

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Bi-level Positive Airway Pressure (BiPAP) with Standard Exhalation Valve Does Not Improve Maximum Exercise Capacity in Patients with COPD

Abstract: Use of BiPAP with a standard exhalation valve during exercise increases VT and VE at the expense of augmenting VCO2 and dyspnea, which in turns reduces WLpeak in COPD patients.

Cited by 5 publications

References 38 publications

Effects of Pressure Support Ventilation May Be Lost at High Exercise Intensities in People with COPD

Effects of Pressure Support Ventilation May Be Lost at High Exercise Intensities in People with COPD

Evaluation of carbon dioxide rebreathing during exercise assisted by noninvasive ventilation with plateau exhalation valve

NIV Is not Adequate for High Intensity Endurance Exercise in COPD

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