title: Extrathoracic expiratory flow limitation in obesity and obstructive and restrictive disorders: effects of increasing negative expiratory pressure.
abstract: BACKGROUND
  The negative expiratory pressure (NEP) technique is used to detect intrathoracic expiratory flow limitation (EFL) in patients with respiratory disorders. Application of NEP may result in a sustained decrease of flow below control as a result of upper airway collapse, which may invalidate interpretation of the test. This response to NEP is common in patients with obstructive sleep apnea syndrome (OSAS). The prevalence of this phenomenon, however, has not been studied in healthy subjects and patients with obstructive and restrictive disorders without OSAS.
  
  
  OBJECTIVE
  The purpose of this study was as follows: (1) to assess the effects of increasing NEP levels on upper airway patency, and (2) to determine the factors that predispose to intrathoracic flow limitation or upper airway collapse during NEP application in different postures in healthy nonobese and obese subjects, and in patients with obstructive and restrictive respiratory disorders.
  
  
  METHODS
  Fifty-six patients with obstructive airway disease (21 patients with COPD, 16 patients with simple chronic bronchitis, and 19 patients with asthma) were compared with 47 patients with restrictive respiratory disorders, 20 nonobese and healthy subjects, and 9 obese subjects (body mass index > 30) without a history of snoring or OSAS.
  
  
  METHODS
  NEP at levels of 5 cm H(2)O, 10 cm H(2)O, and 15 cm H(2)O were applied at the mouth immediately after the onset of tidal expiration while seated and supine. Intrathoracic EFL was defined as no change in expiratory flow over any portion of the immediately preceding control breath. Upper airway collapse or narrowing was detected when flows decreased below those of the control breath.
  
  
  RESULTS
  Ten patients (18%) with obstructive airway disease (7 patients with COPD) exhibited EFL at NEP of 5 cm H(2)O (4 patients were supine only, and 6 patients were both supine and sitting). No patient with restrictive disorders or healthy obese and nonobese subjects presented EFL at NEP of 5 cm H(2)O. In almost all subgroups, both seated and supine, subjects exhibited a transient decrease of flow below control immediately after the application of NEP in occasional breaths. As NEP increased, the number of subjects who exhibited this response in occasional breaths declined, while the number of subjects who displayed this pattern in all breaths increased. Conversely, there were very few subjects in each subgroup who exhibited a sustained decrease in flow below control in occasional breaths at NEP at 5 cm H(2)O, and only one healthy obese subject who displayed this response in all breaths in supine position only.
  
  
  CONCLUSIONS
  In general, an increase in NEP resulted in only rare instances of sustained decrease in flow below control in all breaths. While transient decreases in flow exhibited immediately after the onset of NEP in all breaths are common and become more prevalent as NEP is increased beyond 5 cm H(2)O, there are only rare instances of sustained decrease in flow below control throughout expiration at all levels of NEP tested, indicating an appropriate upper airway dilator response that maintains patency. Thus, in subjects without OSAS, assessment of intrathoracic EFL with NEP is valid in almost all instances.
authors.affiliation: Divisions of Pulmonary and Critical Care Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA. baydur@hsc.usc.edu
authors.forename: Ahmet
authors.initials: A
authors.lastname: Baydur
authors.forename: Louis
authors.initials: L
authors.lastname: Wilkinson
authors.forename: Ramin
authors.initials: R
authors.lastname: Mehdian
authors.forename: Bhupinder
authors.initials: B
authors.lastname: Bains
authors.forename: Joseph
authors.initials: J
authors.lastname: Milic-Emili
mesh_terms: D005260:Female; D006801:Humans; D008171:Lung Diseases / Q000150:complications / Q000503:physiopathology*; D008173:Lung Diseases, Obstructive / Q000150:complications / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D009765:Obesity / Q000150:complications / Q000503:physiopathology*; D012123:Pulmonary Ventilation