Adaptive servo-ventilation: How does it fit into the treatment of central sleep apnoea syndrome? Expert opinions

[Cardiac dysfunction and the obstructive sleep apnoea syndrome]

INTRODUCTION

Cardiac insufficiency affects nearly 2% of the population with increased morbidity/mortality despite advances in therapeutic management. The sleep apnoea syndrome (SAS) is a risk factor for, and cause of aggravation of, myocardial dysfunction.

BACKGROUND

SAS is found in 70% of patients with chronic cardiac failure, 65% of patients with refractory hypertension, 60% of patients with cerebro-vascular accidents and 50% of patients with atrial fibrillation. The associated cardiovascular mortality is multiplied by a factor of 2 to 3. The pathophysiological mechanisms are intermittent nocturnal hypoxia, variations in CO₂ levels, variations in intrathoracic pressure and repeated arrousals from sleep, concurrent with sympathetic hyperactivity, endothelial dysfunction and systemic inflammation.

CONCLUSIONS

SAS and cardiological management in patients presenting with myocardial dysfunction should be combined. It is necessary to pursue the scientific investigations with the aim of determining a precise care pathway and the respective places of each of the cardiological and pulmonary measures.

[Update on the respiratory management of patients with chronic neuromuscular disease]

BACKGROUND

Neuromuscular diseases include a wide range of conditions that may involve potentially life-threatening respiratory complications (infection, respiratory failure).

SURVEILLANCE AND PULMONARY FUNCTION TESTS

For patients with neuromuscular diseases, clinical assessment of respiratory function and regular pulmonary function tests are needed to screen for nocturnal respiratory disorders, weakness of the diaphragm and potential restrictive disorders and/or chronic hypercapnic respiratory insufficiency, possibly with couch deficiency. MANAGEMENT OF NOCTURNAL RESPIRATORY DISORDERS AND CHRONIC RESPIRATORY FAILURE: Nocturnal respiratory assistance is an important phase of care for nocturnal respiratory disorders and chronic respiratory failure. This may involve continuous positive airway pressure, adaptative servo-ventilation or non-invasive ventilation with a facial or nasal mask. As needed, diurnal assistance may be proposed by mouthpiece ventilation. Should non-invasive ventilation prove insufficient, or if significant swallowing disorders or recurrent bronchial obstruction develop, or in case of prolonged intubation, tracheotomy may be required.

LOWER AIRWAY OBSTRUCTION

In case of lower airway infection with ineffective cough, physical therapy, associated with air stacking, intermittent positive pressure breathing or mechanical in-exsufflation may be proposed.

PATIENT-CENTERED MANAGEMENT

Care for swallowing disorders, nutritional counseling (cachexia, obesity), vaccinations and therapeutic education are integral elements of patient-centered management aiming to prevent the negative impact of infection and to manage respiratory failure of chronic neuromuscular disease.

The SERVE-HF safety notice in clinical practice - experiences of a tertiary sleep center

BACKGROUND

In May 2015, the results of the SERVE-HF trial - addressing adaptive servoventilation (ASV) in chronic congestive heart failure (CHF) patients with central sleep apnea (CSA) - prompted a field safety notice. It was recommended to identify CHF patients treated with ASV and to advise the discontinuation of the treatment. We aimed to analyze the identification process and effect of ASV discontinuation on affected patients.

METHODS

126 patients treated with ASV on May 13th, 2015 at our institution were retrospectively analyzed. Treatment decisions, effect of ASV discontinuation and clinical course were followed for a year. Patients on ASV with CHF were compared to those without CHF.

RESULTS

The risk criteria of the safety notice were fulfilled by 10.3% of patients (13/126). Additional echocardiographies were performed in 38%. ASV was discontinued in 93% of patients without adverse events (emergency hospitalization in n = 1). CSA reappeared immediately. Day- or nighttime symptoms were reported by 61%. Symptomatic patients were started on alternative treatments. CHF and non-CHF patients differed in cardiac function and type of SDB. CHF patients had shorter overall treatment duration. Compliance to ASV was similar in both groups with a median usage of 412 min (269; 495)/night in the CHF group and 414.5 min (347; 480) in the non-CHF group.

CONCLUSION

Identification of patients "at risk" is feasible but outcome of discontinuation of ASV cannot be evaluated based on these data. ASV withdrawal in patients with stable chronic CHF and CSA leads to an immediate return of sleep disordered breathing. Symptomatic patients may ask for alternative treatment options.