1
|
Correia S, Sousa S, Drummond M, Pinto P, Staats R, Brito D, Lousada N, Cardoso JS, Moita J. Diagnostic and therapeutic approach of central sleep apnea in heart failure - the role of adaptive servo-ventilation. A statement of the Portuguese society of pulmonology and the Portuguese sleep association. Pulmonology 2023; 29:138-143. [PMID: 35501278 DOI: 10.1016/j.pulmoe.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 10/18/2022] Open
Abstract
It is known that patients with heart failure (HF) have an increased risk of developing central sleep apnoea (CSA), with Cheyne-Stokes respiration. The development of servo-ventilation aimed to treat CSA and improve the quality of life (QoL) of these patients. A large randomized clinical study, SERVE-HF, was conducted in order to test this theory in patients with HF and reduced ejection fraction (HFrEF). The results from this trial seemed to indicate that, in these patients, there was no beneficial effect of the assisted ventilation in CSA treatment. More surprisingly, an increased rate of all-cause or cardiovascular mortality was observed. This has led to dramatic changes in clinical practice, with decreased frequency of servo-ventilation prescription across Europe, including Portugal, due to changes in the guidelines. However, SERVE-HF was conducted only in severe systolic HF patients with CSA, and caution must be taken when extrapolating these results to HF patients with preserved ejection fraction or CSA patients without HF. The study also showed poor adherence, methodological and statistical gaps, including study design, patient selection, data collection and analysis, treatment adherence, and group crossovers, which have not been discussed in the trial as potential confounding factors and raise several concerns. Moreover, the adaptive servo-ventilation (ASV) device used in SERVE-HF was unable to lower the minimum support pressure below 3 mm H20, and this has been suggested as one of the probable contributing reasons to the excess mortality observed in this study. This limitation has since been solved, and this ASV device is no longer used. This paper describes the results of a Portuguese Task Force on the treatment of central sleep apnoea in patients with chronic HF.
Collapse
Affiliation(s)
- S Correia
- Hospital Pedro Hispano, Porto, Portugal.
| | - S Sousa
- Centro Hospitalar de Setubal, Portugal
| | - M Drummond
- Centro Hospitalar Universitario do Porto, Porto, Portugal
| | - P Pinto
- Centro Hospitalar Universitario Lisboa Norte, Lisboa, Portugal
| | - R Staats
- Centro Hospitalar Universitario Lisboa Norte, Lisboa, Portugal
| | - D Brito
- Centro Hospitalar Universitario Lisboa Norte, Lisboa, Portugal
| | - N Lousada
- Centro Hospitalar Universitario Lisboa Norte, Lisboa, Portugal
| | - J S Cardoso
- Centro Hospitalar Universitário de São João, Portugal
| | - J Moita
- Centro Hospitalar e Universitario de Coimbra, Portugal
| |
Collapse
|
2
|
Patterns of adaptive servo-ventilation settings in a real-life multicenter study: pay attention to volume! : Adaptive servo-ventilation settings in real-life conditions. Respir Res 2020; 21:243. [PMID: 32957983 PMCID: PMC7507637 DOI: 10.1186/s12931-020-01509-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 09/13/2020] [Indexed: 01/03/2023] Open
Abstract
Backgrounds To explain the excess cardiovascular mortality observed in the SERVE-HF study, it was hypothesized that the high-pressure ASV default settings used lead to inappropriate ventilation, cascading negative consequences (i.e. not only pro-arrythmogenic effects through metabolic/electrolyte abnormalities, but also lower cardiac output). The aims of this study are: i) to describe ASV-settings for long-term ASV-populations in real-life conditions; ii) to describe the associated minute-ventilations (MV) and therapeutic pressures for servo-controlled-flow versus servo-controlled-volume devices (ASV-F Philips®-devices versus ASV-V ResMed®-devices). Methods The OTRLASV-study is a cross-sectional, 5-centre study including patients who underwent ASV-treatment for at least 1 year. The eight participating clinicians were free to adjust ASV settings, which were compared among i) initial diagnosed sleep-disordered-breathing (SBD) groups (Obstructive-Sleep-Apnea (OSA), Central-Sleep-Apnea (CSA), Treatment-Emergent-Central-Sleep-Apnea (TECSA)), and ii) unsupervised groups (k-means clusters). To generate these clusters, baseline and follow-up variables were used (age, sex, body mass index (BMI), initial diagnosed Obstructive-Apnea-Index, initial diagnosed Central-Apnea-Index, Continuous-Positive-Airway-Pressure used before ASV treatment, presence of cardiopathy, and presence of a reduced left-ventricular-ejection-fraction (LVEF)). ASV-data were collected using the manufacturer’s software for 6 months. Results One hundred seventy-seven patients (87.57% male) were analysed with a median (IQ25–75) initial Apnea-Hypopnea-Index of 50 (38–62)/h, an ASV-treatment duration of 2.88 (1.76–4.96) years, 61.58% treated with an ASV-V. SDB groups did not differ in ASV settings, MV or therapeutic pressures. In contrast, the five generated k-means clusters did (generally described as follows: (C1) male-TECSA-cardiopathy, (C2) male-mostly-CSA-cardiopathy, (C3) male-mostly-TECSA-no cardiopathy, (C4) female-mostly-elevated BMI-TECSA-cardiopathy, (C5) male-mostly-OSA-low-LVEF). Of note, the male-mostly-OSA-low-LVEF-cluster-5 had significantly lower fixed end-expiratory-airway-pressure (EPAP) settings versus C1 (p = 0.029) and C4 (p = 0.007). Auto-EPAP usage was higher in the male-mostly-TECSA-no cardiopathy-cluster-3 versus C1 (p = 0.006) and C2 (p < 0.001). MV differences between ASV-F (p = 0.002) and ASV-V (p < 0.001) were not homogenously distributed across clusters, suggesting specific cluster and ASV-algorithm interactions. Individual ASV-data suggest that the hyperventilation risk is not related to the cluster nor the ASV-monitoring type. Conclusions Real-life ASV settings are associated with combinations of baseline and follow-up variables wherein cardiological variables remain clinically meaningful. At the patient level, a hyperventilation risk exists regardless of cluster or ASV-monitoring type, spotlighting a future role of MV-telemonitoring in the interest of patient-safety. Trial registration The OTRLASV study was registered on ClinicalTrials.gov (Identifier: NCT02429986). 1 April 2015.
Collapse
|
3
|
Brown LK, Javaheri S, Khayat R. A Critical Review of SERVE-HF Follow-Up Studies and Their Impact on Clinical Practice. CURRENT SLEEP MEDICINE REPORTS 2020. [DOI: 10.1007/s40675-020-00177-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
4
|
Cantero C, Adler D, Pasquina P, Uldry C, Egger B, Prella M, Younossian AB, Poncet A, Soccal-Gasche P, Pepin JL, Janssens JP. Adaptive Servo-Ventilation: A Comprehensive Descriptive Study in the Geneva Lake Area. Front Med (Lausanne) 2020; 7:105. [PMID: 32309284 PMCID: PMC7145945 DOI: 10.3389/fmed.2020.00105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 03/09/2020] [Indexed: 12/29/2022] Open
Abstract
Background: Use of adaptive servo-ventilation (ASV) has been questioned in patients with central sleep apnea (CSA) and chronic heart failure (CHF). This study aims to detail the present use of ASV in clinical practice. Methods: Descriptive, cross-sectional, multicentric study of patients undergoing long term (≥3 months) ASV in the Cantons of Geneva or Vaud (1,288,378 inhabitants) followed by public or private hospitals, private practitioners and/or home care providers. Results: Patients included (458) were mostly male (392; 85.6%), overweight [BMI (median, IQR): 29 kg/m2 (26; 33)], comorbid, with a median age of 71 years (59–77); 84% had been treated by CPAP before starting ASV. Indications for ASV were: emergent sleep apnea (ESA; 337; 73.6%), central sleep apnea (CSA; 108; 23.6%), obstructive sleep apnea (7; 1.5%), and overlap syndrome (6; 1.3%). Origin of CSA was cardiac (n = 30), neurological (n = 26), idiopathic (n = 28), or drug-related (n = 22). Among CSA cases, 60 (56%) patients had an echocardiography within the preceding 12 months; median left ventricular ejection fraction (LVEF) was 62.5% (54–65); 11 (18%) had a LVEF ≤45%. Average daily use of ASV was [mean (SD)] 368 (140) min; 13% used their device <3:30 h. Based on ventilator software, apnea-hypopnea index was normalized in 94% of subjects with data available (94% of 428). Conclusions: Use of ASV has evolved from its original indication (CSA in CHF) to a heterogeneous predominantly male, aged, comorbid, and overweight population with mainly ESA or CSA. CSA in CHF represented only 6.5% of this population. Compliance and correction of respiratory events were satisfactory. Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT04054570.
Collapse
Affiliation(s)
- Chloé Cantero
- Division of Pulmonary Diseases, Geneva University Hospitals (HUG), Geneva, Switzerland
| | - Dan Adler
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Respiratory Diseases and Pulmonary Rehabilitation Center, Rolle Hospital, Rolle, Switzerland
| | | | - Christophe Uldry
- Respiratory Diseases and Pulmonary Rehabilitation Center, Rolle Hospital, Rolle, Switzerland
| | - Bernard Egger
- Respiratory Diseases and Pulmonary Rehabilitation Center, Rolle Hospital, Rolle, Switzerland
| | - Maura Prella
- Division of Pulmonary Diseases, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Alain Bigin Younossian
- Division of Pulmonary Diseases and Intensive Care, La Tour Hospital, Geneva, Switzerland
| | - Antoine Poncet
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Center for Clinical Research and Division of Clinical Epidemiology, Department of Health and Community Medicine, University Hospitals of Geneva (HUG), Geneva, Switzerland
| | - Paola Soccal-Gasche
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Respiratory Diseases and Pulmonary Rehabilitation Center, Rolle Hospital, Rolle, Switzerland
| | - Jean-Louis Pepin
- Inserm U1042 Unit, HP2 Laboratory, University Grenoble Alps, Grenoble, France.,EFCR Laboratory, Thorax and Vessels and Vessels, Grenoble Alps University Hospital, Grenoble, France
| | - Jean-Paul Janssens
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Respiratory Diseases and Pulmonary Rehabilitation Center, Rolle Hospital, Rolle, Switzerland
| |
Collapse
|
5
|
Krakow BJ, McIver ND, Obando JJ, Ulibarri VA. Changes in insomnia severity with advanced PAP therapy in patients with posttraumatic stress symptoms and comorbid sleep apnea: a retrospective, nonrandomized controlled study. Mil Med Res 2019; 6:15. [PMID: 31072385 PMCID: PMC6507057 DOI: 10.1186/s40779-019-0204-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 04/11/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sleep disorders frequently occur in posttraumatic stress disorder (PTSD) patients. Chronic insomnia is a common feature of and criteria for the diagnosis of PTSD. Another sleep disorder, obstructive sleep apnea (OSA), also occurs frequently in PTSD, and emerging research indicates OSA fuels chronic insomnia. Scant research has investigated the impact of OSA treatment on insomnia outcomes (Insomnia Severity Index, ISI) in trauma survivors. METHODS OSA patients with moderately severe posttraumatic stress symptoms were studied in a retrospective chart review. Ninety-six patients who failed CPAP therapy due to expiratory pressure intolerance or complex sleep apnea or both underwent manual titration with advanced PAP modes [autobilevel (ABPAP); adaptive servo-ventilation (ASV)], which were subsequently prescribed. PAP use measured by objective data downloads divided the sample into three groups: compliant regular users (C-RU): n = 68; subthreshold users (SC-RU): n = 12; and noncompliant users (NC-MU): n = 16. The average follow-up was 11.89 ± 12.22 months. Baseline and posttreatment ISI scores were analyzed to assess residual insomnia symptoms as well as cure rates. RESULTS The C-RU group showed significant improvements in insomnia with very large effects compared to those in the NC-MU reference group (P = 0.019). Insomnia severity significantly decreased in all three groups with large effects (C-RU, P = 0.001; SC-RU, P = 0.027; NC-MU, P = 0.007). Hours of weekly PAP use and insomnia severity were inversely correlated (P = 0.001, r = - 0.321). However, residual insomnia symptoms based on established ISI cut-offs were quite common, even among the C-RU group. Post hoc analysis showed that several categories of sedating medications reported at baseline (hypnotics, anti-epileptic, opiates) as well as actual use of any sedating medication (prescription or nonprescription) were associated with smaller insomnia improvements than those in patients not using any sedating agents. CONCLUSIONS In a retrospective, nonrandomized analysis of a select sample of sleep clinic patients with OSA and PTSD symptoms, advanced PAP therapy was associated with significant improvement in insomnia severity for both compliant and partial users. However, residual insomnia symptoms persisted, indicating that PAP therapy provides only limited treatment. RCTs are warranted to assess the effect of ABPAP and ASV modes of therapy on adherence and sleep outcomes, and their potential impact on posttraumatic stress symptoms. Treatment arms that combine PAP with CBT-I would be expected to yield the greatest potency.
Collapse
Affiliation(s)
- Barry J Krakow
- Sleep & Human Health Institute, 6739 Academy Rd NE Ste380, Albuquerque, NM, 87109, USA. .,Maimonides Sleep Arts & Sciences, 6739 Academy Rd NE Ste380, Albuquerque, NM, 87109, USA. .,Los Alamos Medical Center, 3917 W Rd, Los Alamos, NM, 87544, USA.
| | - Natalia D McIver
- Sleep & Human Health Institute, 6739 Academy Rd NE Ste380, Albuquerque, NM, 87109, USA.,Maimonides Sleep Arts & Sciences, 6739 Academy Rd NE Ste380, Albuquerque, NM, 87109, USA
| | - Jessica J Obando
- Maimonides Sleep Arts & Sciences, 6739 Academy Rd NE Ste380, Albuquerque, NM, 87109, USA.,Institution: Mozaik Solutions, Solana Beach, CA, 92075, USA
| | - Victor A Ulibarri
- Sleep & Human Health Institute, 6739 Academy Rd NE Ste380, Albuquerque, NM, 87109, USA.,Maimonides Sleep Arts & Sciences, 6739 Academy Rd NE Ste380, Albuquerque, NM, 87109, USA
| |
Collapse
|
6
|
Randerath W. Positive Airway Pressure for Sleep-Related Breathing Disorders in Heart Failure—Overview and Discussion of Potential Mechanisms of Harm. CURRENT SLEEP MEDICINE REPORTS 2018. [DOI: 10.1007/s40675-018-0116-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
7
|
Randerath W, Schumann K, Treml M, Herkenrath S, Castrogiovanni A, Javaheri S, Khayat R. Adaptive servoventilation in clinical practice: beyond SERVE-HF? ERJ Open Res 2017; 3:00078-2017. [PMID: 29204433 PMCID: PMC5703354 DOI: 10.1183/23120541.00078-2017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 08/27/2017] [Indexed: 11/05/2022] Open
Abstract
Adaptive servoventilation (ASV) has proven effective at suppressing breathing disturbances during sleep, improving quality of life and cardiac surrogate parameters. Since the publication of the SERVE-HF-trial, ASV became restricted. The purpose of this study was to evaluate the clinical relevance of the SERVE-HF inclusion criteria in real life and estimate the portion of patients with these criteria with or without risk factors who are undergoing ASV treatment. We performed a retrospective study of all patients who were treated with ASV in a university-affiliated sleep laboratory. We reviewed the history of cardiovascular diseases, echocardiographic measurements of left ventricular ejection fraction (LVEF) and polysomnography. From 1998 to 2015, 293 patients received ASV, of which 255 (87.0%) had cardiovascular diseases and 118 (40.3%) had HF. Among those with HF, the LVEF was ≤45% in 47 patients (16.0%). Only 12 patients (4.1%) had LVEF <30%. The SERVE-HF inclusion criteria were present in 28 (9.6%) ASV recipients. Of these patients, 3 died within 30–58 months of therapy, all with systolic HF and a LVEF <30%. In this study, only a small minority of ASV patients fell in the risk group. The number of fatalities did not exceed the expected mortality in optimally treated systolic HF patients. The majority of ASV patients do not fulfil the risk criteria. Fatalities under ASV did not exceed expected figures.http://ow.ly/V2HI30fBURh
Collapse
Affiliation(s)
- Winfried Randerath
- Institute of Pneumology at the University of Cologne, Bethanien Hospital, Clinic for Pneumology and Allergology, Centre of Sleep Medicine and Respiratory Care, Solingen, Germany.,These authors contributed equally
| | - Katja Schumann
- Institute of Pneumology at the University of Cologne, Bethanien Hospital, Clinic for Pneumology and Allergology, Centre of Sleep Medicine and Respiratory Care, Solingen, Germany.,These authors contributed equally
| | - Marcel Treml
- Institute of Pneumology at the University of Cologne, Bethanien Hospital, Clinic for Pneumology and Allergology, Centre of Sleep Medicine and Respiratory Care, Solingen, Germany
| | - Simon Herkenrath
- Institute of Pneumology at the University of Cologne, Bethanien Hospital, Clinic for Pneumology and Allergology, Centre of Sleep Medicine and Respiratory Care, Solingen, Germany
| | - Alessandra Castrogiovanni
- Institute of Pneumology at the University of Cologne, Bethanien Hospital, Clinic for Pneumology and Allergology, Centre of Sleep Medicine and Respiratory Care, Solingen, Germany
| | - Shahrokh Javaheri
- Bethesda North Hospital, Cincinnati, OH, USA.,Pulmonary Diseases and Sleep, University of Cincinnati, Cincinnati, OH, USA
| | - Rami Khayat
- Division of Pulmonary Critical Care and Sleep, Ohio State University, Columbus, OH, USA
| |
Collapse
|
8
|
Withdrawing ASV therapy in clinical practice: trials and tribulations. Sleep Med 2017; 37:208-209. [DOI: 10.1016/j.sleep.2017.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 03/01/2017] [Indexed: 11/20/2022]
|