{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,8]],"date-time":"2026-01-08T08:00:37Z","timestamp":1767859237611,"version":"3.49.0"},"reference-count":44,"publisher":"European Respiratory Society (ERS)","issue":"3","license":[{"start":{"date-parts":[[2020,5,22]],"date-time":"2020-05-22T00:00:00Z","timestamp":1590105600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/www.ersjournals.com\/user-licence"}],"funder":[{"DOI":"10.13039\/501100000380","name":"Guy's and St Thomas' Charity","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100000380","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100004320","name":"Philips","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100004320","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["publications.ersnet.org"],"crossmark-restriction":true},"short-container-title":["Eur Respir J"],"accepted":{"date-parts":[[2020,5,1]]},"published-print":{"date-parts":[[2020,9]]},"abstract":"<jats:sec><jats:title>Background<\/jats:title><jats:p>The optimal noninvasive application of external positive end-expiratory pressure (EPAP) to abolish tidal-breathing expiratory flow limitation (EFL<jats:sub>T<\/jats:sub>) and minimise intrinsic positive end-expiratory pressure (PEEP<jats:sub>i<\/jats:sub>) is challenging in COPD patients. We investigated whether auto-titrating EPAP, using the forced oscillation technique (FOT) to detect and abolish EFL<jats:sub>T<\/jats:sub>, would minimise PEEP<jats:sub>i<\/jats:sub>, work of breathing and neural respiratory drive (NRD) in patients with severe COPD.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Patients with COPD with chronic respiratory failure underwent auto-titration of EPAP using a FOT-based algorithm that detected EFL<jats:sub>T<\/jats:sub>. Once optimal EPAP was identified, manual titration was performed to assess NRD (using diaphragm and parasternal intercostal muscle electromyography, EMG<jats:sub>di<\/jats:sub>and EMG<jats:sub>para<\/jats:sub>, respectively), transdiaphragmatic inspiratory pressure swings (\u0394<jats:italic>P<\/jats:italic><jats:sub>di<\/jats:sub>), transdiaphragmatic pressure\u2013time product (PTP<jats:sub>di<\/jats:sub>) and PEEP<jats:sub>i<\/jats:sub>, between EPAP levels 2\u2005cmH<jats:sub>2<\/jats:sub>O below to 3\u2005cmH<jats:sub>2<\/jats:sub>O above optimal EPAP.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Of 10 patients enrolled (age 65\u00b16\u2005years; male 60%; body mass index 27.6\u00b17.2\u2005kg.m<jats:sup>\u22122<\/jats:sup>; forced expiratory volume in 1\u2005s 28.4\u00b18.3% predicted), eight had EFL<jats:sub>T<\/jats:sub>, and optimal EPAP was 9 (range 4\u201313) cmH<jats:sub>2<\/jats:sub>O. NRD was reduced from baseline EPAP at 1\u2005cmH<jats:sub>2<\/jats:sub>O below optimal EPAP on EMG<jats:sub>di<\/jats:sub>and at optimal EPAP on EMG<jats:sub>para<\/jats:sub>. In addition, at optimal EPAP, PEEP<jats:sub>i<\/jats:sub>(0.80\u00b11.27\u2005cmH<jats:sub>2<\/jats:sub>O<jats:italic>versus<\/jats:italic>1.95\u00b1 1.70\u2005cmH<jats:sub>2<\/jats:sub>O; p&lt;0.05) was reduced compared with baseline. PTP<jats:sub>di<\/jats:sub>(10.3\u00b17.8\u2005cmH<jats:sub>2<\/jats:sub>O\u00b7s<jats:sup>\u22121<\/jats:sup><jats:italic>versus<\/jats:italic>16.8\u00b18.8\u2005cmH<jats:sub>2<\/jats:sub>O\u00b7s<jats:sup>\u22121<\/jats:sup>; p&lt;0.05) and \u0394<jats:italic>P<\/jats:italic><jats:sub>di<\/jats:sub>(12.4\u00b17.8\u2005cmH<jats:sub>2<\/jats:sub>O<jats:italic>versus<\/jats:italic>18.2\u00b15.1\u2005cmH<jats:sub>2<\/jats:sub>O; p&lt;0.05) were reduced at optimal EPAP+1\u2005cmH<jats:sub>2<\/jats:sub>O compared with baseline.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>Autotitration of EPAP, using a FOT-based algorithm to abolish EFL<jats:sub>T<\/jats:sub>, minimises transdiaphragmatic pressure swings and NRD in patients with COPD and chronic respiratory failure.<\/jats:p><\/jats:sec>","DOI":"10.1183\/13993003.02234-2019","type":"journal-article","created":{"date-parts":[[2020,5,22]],"date-time":"2020-05-22T18:30:07Z","timestamp":1590172207000},"page":"1902234","update-policy":"https:\/\/doi.org\/10.1183\/ers-crossmark-policy","source":"Crossref","is-referenced-by-count":19,"title":["Autotitrating external positive end-expiratory airway pressure to abolish expiratory flow limitation during tidal breathing in patients with severe COPD: a physiological 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