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Background  The optimal noninvasive application of external positive end-expiratory pressure (EPAP) to abolish tidal-breathing expiratory flow limitation (EFL T ) and minimise intrinsic positive end-expiratory pressure (PEEP i ) is challenging in COPD patients. We investigated whether auto-titrating EPAP, using the forced oscillation technique (FOT) to detect and abolish EFL T , would minimise PEEP i , work of breathing and neural respiratory drive (NRD) in patients with severe COPD.    Methods  Patients with COPD with chronic respiratory failure underwent auto-titration of EPAP using a FOT-based algorithm that detected EFL T . Once optimal EPAP was identified, manual titration was performed to assess NRD (using diaphragm and parasternal intercostal muscle electromyography, EMG di  and EMG para , respectively), transdiaphragmatic inspiratory pressure swings (Δ P  di ), transdiaphragmatic pressure–time product (PTP di ) and PEEP i , between EPAP levels 2 cmH 2 O below to 3 cmH 2 O above optimal EPAP.    Results  Of 10 patients enrolled (age 65±6 years; male 60%; body mass index 27.6±7.2 kg.m −2 ; forced expiratory volume in 1 s 28.4±8.3% predicted), eight had EFL T , and optimal EPAP was 9 (range 4–13) cmH 2 O. NRD was reduced from baseline EPAP at 1 cmH 2 O below optimal EPAP on EMG di  and at optimal EPAP on EMG para . In addition, at optimal EPAP, PEEP i  (0.80±1.27 cmH 2 O  versus  1.95± 1.70 cmH 2 O; p&lt;0.05) was reduced compared with baseline. PTP di  (10.3±7.8 cmH 2 O·s −1  versus  16.8±8.8 cmH 2 O·s −1 ; p&lt;0.05) and Δ P  di  (12.4±7.8 cmH 2 O  versus  18.2±5.1 cmH 2 O; p&lt;0.05) were reduced at optimal EPAP+1 cmH 2 O compared with baseline.    Conclusion  Autotitration of EPAP, using a FOT-based algorithm to abolish EFL T , minimises transdiaphragmatic pressure swings and NRD in patients with COPD and chronic respiratory failure.

european respiratory journal/the european respiratory journal

Autotitrating external positive end-expiratory airway pressure to abolish expiratory flow limitation during tidal breathing in patients with severe COPD: a physiological study