title: Videolaryngoscopy With Noninvasive Ventilation in Subjects With Upper-Airway Obstruction.
abstract: BACKGROUND
  Noninvasive ventilation (NIV) titration may be difficult when dynamic airway obstruction episodes persist, even with high expiratory positive airway pressure (EPAP). We aimed to determine the usefulness of videolaryngoscopy during NIV for identifying mechanisms and sites of obstruction and for providing a guide for their resolution in difficult-to-titrate subjects.
  
  
  METHODS
  When obstructions during NIV were present in the built-in software, EPAP was raised to 12 cm H2O. If obstructions persisted, a polygraphy during NIV was performed; if the events occurred with effort, a videolaryngoscopy with nasal and oronasal masks in awake subjects was performed.
  
  
  RESULTS
  In a population of 208 subjects in whom NIV was initiated, 13 were identified as difficult to titrate with persistent obstructions during NIV despite an EPAP of 12 cm H2O. Videolaryngoscopy during NIV was able to identify the mechanism and the site of obstruction in all cases. The obstruction under oronasal mask ventilation was due to soft-palate (velum) collapse in 4 subjects, to epiglottic backward movement in 5 other subjects, and to tongue-base obstruction reducing the retroglossal space in 3 more. Videolaryngoscopy during NIV demonstrated improvement in 9 subjects (69%) upon changing to nasal mask and suggested a possible surgical approach in 2 (15%); in one of these 2 subjects, a successful uvulopalatopharyngoplasty was performed.
  
  
  CONCLUSIONS
  The use of videolaryngoscopy during NIV in difficult-to-titrate patients may help to identify the sites and mechanisms of obstruction and in some cases may improve quality of ventilation.
authors.affiliation: Servicio de Neumología, Hospital Universitario 12 de Octubre, Madrid, Spain. jsayascat@gmail.com.
authors.forename: Javier
authors.initials: J
authors.lastname: Sayas Catalán
authors.affiliation: Otorhinolaryngology Department, Servicio de Neumología, Hospital Universitario 12 de Octubre, Madrid, Spain.
authors.forename: Ignacio
authors.initials: I
authors.lastname: Jiménez Huerta
authors.affiliation: Servicio de Neumología, Hospital Universitario 12 de Octubre, Madrid, Spain.
authors.forename: Pedro
authors.initials: P
authors.lastname: Benavides Mañas
authors.affiliation: Servei de Pneumologia, Corporaciò Sanitària Parc Taulí, Hospital de Sabadell, Universitat Autònoma de Barcelona, Parc Taulí, Sabadell and CIBERES, Instituto de Salud Carlos III, Madrid, Spain.
authors.forename: Manel
authors.initials: M
authors.lastname: Luján
authors.affiliation: Servicio de Neumología, Hospital Universitario 12 de Octubre, Madrid, Spain.|Fundación para la Investigación Biomédica del Hospital General Universitario Gregorio Marañón, Madrid, Spain.
authors.forename: Daniel
authors.initials: D
authors.lastname: López-Padilla
authors.affiliation: Servicio de Neumología, Hospital Universitario 12 de Octubre, Madrid, Spain.
authors.forename: Eva
authors.initials: E
authors.lastname: Arias Arias
authors.affiliation: Servicio de Neumología, Hospital Universitario 12 de Octubre, Madrid, Spain.
authors.forename: Ana
authors.initials: A
authors.lastname: Hernández Voth
authors.affiliation: Service de Pneumologie et Soins Intensifs Respiratoire, Centre Hospitalier Universitaire de Dijon, Dijon, France.
authors.forename: Claudio
authors.initials: C
authors.lastname: Rabec
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000402:Airway Obstruction / Q000000981:diagnostic imaging* / Q000209:etiology / Q000628:therapy*; D004825:Epiglottis / Q000503:physiopathology; D005260:Female; D006801:Humans; D007828:Laryngoscopy / Q000379:methods*; D008297:Male; D008397:Masks / Q000009:adverse effects; D008875:Middle Aged; D063087:Noninvasive Ventilation / Q000295:instrumentation*; D010160:Palate, Soft / Q000503:physiopathology; D011312:Pressure; D014059:Tongue / Q000503:physiopathology
keywords: bi-level CPAP; laryngoscopy; noninvasive ventilation; polysomnography; respiratory insufficiency