• Javier Sayas Catalán, Ignacio Jiménez Huerta, Pedro Benavides Mañas, Manel Luján, Daniel López-Padilla, Eva Arias Arias, Ana Hernández Voth, and Claudio Rabec.
• Servicio de Neumología, Hospital Universitario 12 de Octubre, Madrid, Spain. jsayascat@gmail.com.
• Respir Care. 2017 Feb 1; 62 (2): 222-230.

BackgroundNoninvasive 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.MethodsWhen 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.ResultsIn 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.ConclusionsThe 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.Copyright © 2017 by Daedalus Enterprises.

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