Inhibitory Effect of Nasal Intermittent Positive Pressure Ventilation on Gastroesophageal Reflux

Abstract

Non-invasive intermittent positive pressure ventilation can lead to esophageal insufflations and in turn to gastric distension. The fact that the latter induces transient relaxation of the lower esophageal sphincter implies that it may increase gastroesophageal refluxes. We previously reported that nasal Pressure Support Ventilation (nPSV), contrary to nasal Neurally-Adjusted Ventilatory Assist (nNAVA), triggers active inspiratory laryngeal closure. This suggests that esophageal insufflations are more frequent in nPSV than in nNAVA. The objectives of the present study were to test the hypotheses that: i) gastroesophageal refluxes are increased during nPSV compared to both control condition and nNAVA; ii) esophageal insufflations occur more frequently during nPSV than nNAVA. Polysomnographic recordings and esophageal multichannel intraluminal impedance pHmetry were performed in nine chronically instrumented newborn lambs to study gastroesophageal refluxes, esophageal insufflations, states of alertness, laryngeal closure and respiration. Recordings were repeated without sedation in control condition, nPSV (15/4 cmH2O) and nNAVA (~ 15/4 cmH2O). The number of gastroesophageal refluxes recorded over six hours, expressed as median (interquartile range), decreased during both nPSV (1 (0, 3)) and nNAVA [1 (0, 3)] compared to control condition (5 (3, 10)), (p < 0.05). Meanwhile, the esophageal insufflation index did not differ between nPSV (40 (11, 61) h-1) and nNAVA (10 (9, 56) h-1) (p = 0.8). In conclusion, nPSV and nNAVA similarly inhibit gastroesophageal refluxes in healthy newborn lambs at pressures that do not lead to gastric distension. In addition, the occurrence of esophageal insufflations is not significantly different between nPSV and nNAVA. The strong inhibitory effect of nIPPV on gastroesophageal refluxes appears identical to that reported with nasal continuous positive airway pressure.

The influence of Intrapulmonary percussive ventilation on gastroesophageal reflux in infants under the age of 1 year

“…[22][23][24] Nasal intermittent positive pressure ventilation and nasal high-frequency oscillatory ventilation were reported to inhibit GER in full-term newborn lambs. 25,26 These findings do also supports the previous hypothesis on the importance of LES relaxations. The hypothesis proposed is that the caudal displacement of the diaphragm and mediastinum can cause lengthening of the esophagus, and therefore diminish the ability of the esophageal longitudinal muscle to generate transient lower esophageal sphincter relaxations.…”

“…The hypothesis proposed is that the caudal displacement of the diaphragm and mediastinum can cause lengthening of the esophagus, and therefore diminish the ability of the esophageal longitudinal muscle to generate transient lower esophageal sphincter relaxations. 25,27 The ability to displace the LES decreases and the LES relaxation will be disturbed. 25,27 The effect of this caudal displacement of the diaphragm might hinder the buttressing effect of the diaphragmatic crura on the LES: lengthening Former studies concerning chest physiotherapy and its effect on GER mainly focus on positioning the child with head-down tilt possibly in combination with percussion, vibrations, chest clapping, and thoracic compression.…”

“…25,27 The ability to displace the LES decreases and the LES relaxation will be disturbed. 25,27 The effect of this caudal displacement of the diaphragm might hinder the buttressing effect of the diaphragmatic crura on the LES: lengthening Former studies concerning chest physiotherapy and its effect on GER mainly focus on positioning the child with head-down tilt possibly in combination with percussion, vibrations, chest clapping, and thoracic compression. Besides the lack of evidence on the effectiveness of these techniques, the use of gravity-assisted positions is not recommended.…”

Long-Term Non-invasive Ventilation in Children: Current Use, Indications, and Contraindications

“…An oronasal mask must not be used in such circumstances ( 65 ). The decision to proceed to a trial of LT-NIV with a nasal mask should take into account evidence from human and animal studies showing that positive airway pressure therapy, including NIV, can inhibit gastroesophageal reflux ( 66 , 67 ).…”

Nutritional and Gastrointestinal Management of the Patient With Duchenne Muscular Dystrophy

“…Evidence suggests that the use of positivepressure ventilation may protect against gastroesophageal reflux events. 42,43 Slowed gastric emptying has been reported in children with DMD and may worsen over time. 44,45 This problem can mimic gastroesophageal reflux symptoms, leading to postprandial abdominal pain, early satiety, nausea, and vomiting.…”