Thoracoabdominal Asynchrony in Acute Upper Airway Obstruction in Small Children

Sivan, Yakov; Deakers, Timothy; Newth, Christopher J L

doi:10.1164/ajrccm/142.3.540

Cited by 92 publications

(82 citation statements)

References 4 publications

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Section: Discussionsupporting

confidence: 71%

“…At baseline, the majority of patients had moderate and severe asynchronous breathing patterns that may correlate with clinical observations of UAO [15,16]. In the present study, five patients had breathing movements that were comparable with healthy, awake children where the phase angle is v30u [16]. MOTOYAMA [3] studied 13 children suffering from clinically significant UAO when a 2 minimum alveolar concentration (MAC: the alveolar concentration of an inhaled anaesthetic that prevents movement in 50% of patients in response to a standardized stimulus, e.g.…”

Section: Discussionmentioning

confidence: 57%

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Effect of airway opening manoeuvres on thoraco-abdominal asynchrony in anaesthetized children

Reber¹,

Bobbià²,

Hammer³

et al. 2001

Eur Respir J

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Thoraco-abdominal asynchrony is frequently encountered during inhalation anaesthesia in children with adenotonsillar hypertrophy causing an upper airway obstruction. The study goal was to evaluate the impact of different airway opening manoeuvres on thoraco-abdominal asynchrony as a measure of airway obstruction.Thirty anaesthetized children (aged 2 -8 yrs; sevoflurane 3% in 50% oxygen/nitrous oxide) were studied prior to elective adenotonsillectomy using respiratory inductance plethysmography to record ribcage and abdominal wave forms as a basis for calculation of the phase angle. Five airway situations were compared: 1) baseline (unsupported mandible); 2) chin lift; 3) chin lift combined with continuous positive airway pressure of 10 cmH 2 O; 4) jaw thrust; and 5) jaw thrust combined with continuous positive airway pressure of 10 cmH 2 O.Three children had complete upper airway obstruction at baseline and were excluded from the study. With chin lift, thoraco-abdominal asynchrony improved in three patients, worsened in three patients and was unchanged in 21 patients. Additional continuous positive airway pressure during chin lift did not markedly reduce thoracoabdominal asynchrony (phase angle 89¡43u, p~0.33). Jaw thrust resulted in a significant decrease of the phase angle (from 106¡53u at baseline to 65¡49u, pv0.01); when combined with continuous positive airway pressure, no further effect on thoracoabdominal asynchrony was found (72¡44u).In anaesthetized children with adenotonsillar hypertrophy, airway opening manoeuvres have distinct effects on thoraco-abdominal asynchrony. Delivery of continuous positive airway pressure and jaw thrust can be the first airway opening manoeuvres to improve breathing patterns. Chin lift without additional continuous positive airway pressure should be used with caution in these patients because it may convert partial into almost complete airway obstruction.

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Section: Discussionsupporting

confidence: 71%

Section: Discussionmentioning

confidence: 57%

Effect of airway opening manoeuvres on thoraco-abdominal asynchrony in anaesthetized children

Reber¹,

Bobbià²,

Hammer³

et al. 2001

Eur Respir J

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“…External loads of the respiratory system as well as internal loads from changes in pulmonary mechanics secondary to a disease process increase TAA in neonates and infants (2,7,34). The removal of the load has been shown to improve synchrony and distortion (2,34).…”

Section: Discussionmentioning

confidence: 99%

“…The removal of the load has been shown to improve synchrony and distortion (2,34). PAV provided unloading of the respiratory system by removal of the resistive load of the ETT and the disease-related internal elastic load of the lungs.…”

Section: Discussionmentioning

confidence: 99%

Proportional Assist Ventilation Decreases Thoracoabdominal Asynchrony and Chest Wall Distortion in Preterm Infants

et al. 2001

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Thoracoabdominal asynchrony (TAA) and chest wall distortion (CWD) are commonly seen in preterm infants secondary to a highly compliant rib cage and poor compensation of distorting forces by inspiratory rib cage muscles. Continuous positive airway pressure (CPAP) reduces TAA and CWD by stenting the chest wall. We hypothesized that application of positive airway pressure only during inspiration and in proportion to an infant's inspiratory effort should have a similar but more pronounced effect than CPAP alone. A ventilator providing airway pressure changes in proportion to flow and volume generated by an infant (proportional assist ventilation) was used to unload the respiratory pump during inspiration. Ten preterm infants were studied [birth weight, 745 (635-1175) g; gestational age, 26.5 (24 -31) wk; postnatal age 3 (1-7) d; medium (range)]. TAA and CWD were determined by respiratory inductive plethysmography. TAA was expressed as the phase angle between the rib cage and abdominal motion and CWD as the total compartmental displacement ratio. In addition, we measured tidal volume with a pneumotachograph and esophageal and airway pressure deflections with pressure transducers. Measurements were obtained during alternating periods of CPAP and two different degrees of support (Gain 1 ϭ 1.09 Ϯ 0.68, Gain 2 ϭ 1.84 Ϯ 0.84 cm H 2 O/mL) that were provided by a proportional assist ventilator. Phase angle and the total compartmental displacement ratio decreased with increasing gain compared with CPAP alone. Peak airway pressure increased from 0.6 to 3.8 to 7.6 cm H 2 O above positive end-expiratory pressure (PEEP) with CPAP, Gain 1, and Gain 2, respectively, as tidal volume increased from 2.8 to 4.1 to 4.7 mL/kg. Esophageal pressure changes decreased only little with increasing gain. Chest wall excursion increased and abdominal movement decreased, indicating a redistribution of tidal volume between chest and abdomen. We conclude that proportional assist ventilation reduces TAA and CWD by generating a small increase in airway pressure that occurs in synchrony and in proportion to each inspiratory effort. TAA, in which the rib cage and abdomen move out of phase due to inward CWD, are commonly seen in spontaneously breathing preterm infants. TAA and CWD are more pronounced in the presence of decreased lung compliance or increased airway resistance but can also be seen in preterm infants without lung disease or in term infants during REM sleep (1-4). The phenomenon is caused by mainly two factors: the negativity of the pleural pressure generated during inspiration and the compliance of the chest wall (5-7). For the chest wall to move along the pressure/volume curve seen during passive inflation of the respiratory system, active compensation from the inspiratory chest wall muscles, counteracting the distorting pleural force, is necessary (8). It has been shown that the more immature the infants are, the less well developed is their active compensation (9). It may be completely absent in very immature infants, leading to a 180...

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“…Epinephrine by nebulisation alone was found to be as effective as nebulisation using intermittent positive pressure breathing [218]. Substantial improvement after treatment with epinephrine has also been shown in five prospective studies investigating various objective measures of severity; the clinical effect was found to be sustained for at o1 h [219][220][221][222][223][224]. An RCT showed L-epinephrine 1:1,000 to be as effective as racemic epinephrine [225].…”

Section: Epinephrinementioning

confidence: 99%

Medicines used in respiratory diseases only seen in children

Lenney¹,

Al²,

Bont³

et al. 2009

Eur Respir J

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Detailed literature searches were carried out in seven respiratory disease areas. Therapeutic evidence for efficacy of medicinal products was assessed using the Grades of Recommendation, Assessment and Evaluation (GRADE) methodology, as well as an assessment of safety and side-effects.Systemic corticosteroids may reduce the development of bronchopulmonary dysplasia but have serious side-effects. Antioxidants need further study to demonstrate whether they have long-term benefits. Treatments for acute bronchiolitis have shown little benefit but new antiviral and monoclonal antibodies need further assessment. Well-constructed studies are needed to confirm the value of inhaled corticosteroids and/or montelukast in the management of viralinduced wheeze. Corticosteroids are the treatment of choice in croup. Minimal or no information is available for the treatment of congenital lung abnormalities, bronchiolitis obliterans and interstitial lung disease.

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Thoracoabdominal Asynchrony in Acute Upper Airway Obstruction in Small Children

Cited by 92 publications

References 4 publications

Effect of airway opening manoeuvres on thoraco-abdominal asynchrony in anaesthetized children

Effect of airway opening manoeuvres on thoraco-abdominal asynchrony in anaesthetized children

Proportional Assist Ventilation Decreases Thoracoabdominal Asynchrony and Chest Wall Distortion in Preterm Infants

Medicines used in respiratory diseases only seen in children

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