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Sun P, Porter K, Randerath W, Jarjoura D, Khayat R. Adaptive servo-ventilation and mortality in patients with systolic heart failure and central sleep apnea: a single-center experience. Sleep Breath 2023; 27:1909-1915. [PMID: 36920657 PMCID: PMC10539434 DOI: 10.1007/s11325-023-02807-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/24/2023] [Accepted: 03/06/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Central sleep apnea (CSA) is associated with increased mortality and morbidity in patients with heart failure with reduced ejection fraction (HFrEF). Treatment of CSA with a certain type of adaptive servo-ventilation (ASV) device that targets minute ventilation (ASVmv) was found to be harmful in these patients. A newer generation of ASV devices that target peak flow (ASVpf) is presumed to have different effects on ventilation and airway patency. We analyzed our registry of patients with HFrEF-CSA to examine the effect of exposure to ASV and role of each type of ASV device on mortality. METHODS This is a retrospective cohort study in patients with HFrEF and CSA who were treated with ASV devices between 2008 and 2015 at a single institution. Mortality data were collected through the institutional data honest broker. Usage data were obtained from vendors' and manufacturers' servers. Median follow-up was 64 months. RESULTS The registry included 90 patients with HFrEF-CSA who were prescribed ASV devices. Applying a 3-h-per-night usage cutoff, we found a survival advantage at 64 months for those who used the ASV device above the cutoff (n = 59; survival 76%) compared to those who did not (n = 31; survival 49%; hazard ratio 0.44; CI 95%, 0.20 to 0.97; P = 0.04). The majority (n = 77) of patients received ASVpf devices with automatically adjusting end-expiratory pressure (EPAP) and the remainder (n = 13) received ASVmv devices mostly with fixed EPAP (n = 12). There was a trend towards a negative correlation between ASVmv with fixed EPAP and survival. CONCLUSION In this population of patients with HFrEF and CSA, there was no evidence that usage of ASV devices was associated with increased mortality. However, there was evidence of differential effects of type of ASV technology on mortality.
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Affiliation(s)
- Paulina Sun
- The UCI Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, University of California-Irvine, 20350 SW Birch Street, Newport Beach, CA, 92660, USA.
| | - Kyle Porter
- The Center for Biostatistics, The Ohio State University, Columbus, OH, USA
| | - Winfried Randerath
- Institute of Pneumology at the University Cologne, Bethanien Hospital, Solingen, Germany
| | - David Jarjoura
- The Center for Biostatistics, The Ohio State University, Columbus, OH, USA
| | - Rami Khayat
- The UCI Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, University of California-Irvine, 20350 SW Birch Street, Newport Beach, CA, 92660, USA
- Division of Pulmonary and Critical Care Medicine, The Sleep Heart Program, The Ohio State University, Columbus, OH, USA
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Bradicich M, Siciliano M, Donfrancesco F, Cherneva R, Ferraz B, Testelmans D, Sánchez-de-la-Torre M, Randerath W, Schiza S, Cruz J. Sleep and Breathing Conference highlights 2023: a summary by ERS Assembly 4. Breathe (Sheff) 2023; 19:230168. [PMID: 38020339 PMCID: PMC10644110 DOI: 10.1183/20734735.0168-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/08/2023] [Indexed: 12/01/2023] Open
Abstract
This paper presents some of the highlights of the Sleep and Breathing Conference 2023 https://bit.ly/46MxJml.
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Affiliation(s)
- Matteo Bradicich
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- Department of Internal Medicine, Spital Zollikerberg, Zollikerberg, Switzerland
| | - Matteo Siciliano
- Università Cattolica del Sacro Cuore, Campus di Roma, Rome, Italy
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- These authors contributed equally
| | - Federico Donfrancesco
- Università Cattolica del Sacro Cuore, Campus di Roma, Rome, Italy
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- These authors contributed equally
| | - Radostina Cherneva
- Medical University, University Hospital “Ivan Rilski”, Respiratory Intensive Care Unit, Sofia, Bulgaria
- These authors contributed equally
| | - Beatriz Ferraz
- Pulmonology Department, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- These authors contributed equally
| | - Dries Testelmans
- Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
- These authors contributed equally
| | - Manuel Sánchez-de-la-Torre
- Respiratory Department, Hospital Universitari Arnau de Vilanova-Santa María, IRB Lleida, Lleida, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Winfried Randerath
- Institute of Pneumology, University Cologne, Bethanien Hospital, Solingen, Germany
- These authors contributed equally
| | - Sophia Schiza
- Department of Respiratory Medicine, School of Medicine, University of Crete, Heraklion, Greece
- These authors contributed equally
| | - Joana Cruz
- Center for Innovative Care and Health Technology (ciTechCare), School of Health Sciences (ESSLei), Polytechnic of Leiria, Leiria, Portugal
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Chang JL, Goldberg AN, Alt JA, Alzoubaidi M, Ashbrook L, Auckley D, Ayappa I, Bakhtiar H, Barrera JE, Bartley BL, Billings ME, Boon MS, Bosschieter P, Braverman I, Brodie K, Cabrera-Muffly C, Caesar R, Cahali MB, Cai Y, Cao M, Capasso R, Caples SM, Chahine LM, Chang CP, Chang KW, Chaudhary N, Cheong CSJ, Chowdhuri S, Cistulli PA, Claman D, Collen J, Coughlin KC, Creamer J, Davis EM, Dupuy-McCauley KL, Durr ML, Dutt M, Ali ME, Elkassabany NM, Epstein LJ, Fiala JA, Freedman N, Gill K, Boyd Gillespie M, Golisch L, Gooneratne N, Gottlieb DJ, Green KK, Gulati A, Gurubhagavatula I, Hayward N, Hoff PT, Hoffmann OM, Holfinger SJ, Hsia J, Huntley C, Huoh KC, Huyett P, Inala S, Ishman SL, Jella TK, Jobanputra AM, Johnson AP, Junna MR, Kado JT, Kaffenberger TM, Kapur VK, Kezirian EJ, Khan M, Kirsch DB, Kominsky A, Kryger M, Krystal AD, Kushida CA, Kuzniar TJ, Lam DJ, Lettieri CJ, Lim DC, Lin HC, Liu SY, MacKay SG, Magalang UJ, Malhotra A, Mansukhani MP, Maurer JT, May AM, Mitchell RB, Mokhlesi B, Mullins AE, Nada EM, Naik S, Nokes B, Olson MD, Pack AI, Pang EB, Pang KP, Patil SP, Van de Perck E, Piccirillo JF, Pien GW, Piper AJ, Plawecki A, Quigg M, Ravesloot MJ, Redline S, Rotenberg BW, Ryden A, Sarmiento KF, Sbeih F, Schell AE, Schmickl CN, Schotland HM, Schwab RJ, Seo J, Shah N, Shelgikar AV, Shochat I, Soose RJ, Steele TO, Stephens E, Stepnowsky C, Strohl KP, Sutherland K, Suurna MV, Thaler E, Thapa S, Vanderveken OM, de Vries N, Weaver EM, Weir ID, Wolfe LF, Tucker Woodson B, Won CH, Xu J, Yalamanchi P, Yaremchuk K, Yeghiazarians Y, Yu JL, Zeidler M, Rosen IM. International Consensus Statement on Obstructive Sleep Apnea. Int Forum Allergy Rhinol 2023; 13:1061-1482. [PMID: 36068685 PMCID: PMC10359192 DOI: 10.1002/alr.23079] [Citation(s) in RCA: 62] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA). METHODS Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus. RESULTS The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated. CONCLUSION This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.
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Affiliation(s)
- Jolie L. Chang
- University of California, San Francisco, California, USA
| | | | | | | | - Liza Ashbrook
- University of California, San Francisco, California, USA
| | | | - Indu Ayappa
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | - Maurits S. Boon
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Pien Bosschieter
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | - Itzhak Braverman
- Hillel Yaffe Medical Center, Hadera Technion, Faculty of Medicine, Hadera, Israel
| | - Kara Brodie
- University of California, San Francisco, California, USA
| | | | - Ray Caesar
- Stone Oak Orthodontics, San Antonio, Texas, USA
| | | | - Yi Cai
- University of California, San Francisco, California, USA
| | | | | | | | | | | | | | | | | | - Susmita Chowdhuri
- Wayne State University and John D. Dingell VA Medical Center, Detroit, Michigan, USA
| | - Peter A. Cistulli
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - David Claman
- University of California, San Francisco, California, USA
| | - Jacob Collen
- Uniformed Services University, Bethesda, Maryland, USA
| | | | | | - Eric M. Davis
- University of Virginia, Charlottesville, Virginia, USA
| | | | | | - Mohan Dutt
- University of Michigan, Ann Arbor, Michigan, USA
| | - Mazen El Ali
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | - Kirat Gill
- Stanford University, Palo Alto, California, USA
| | | | - Lea Golisch
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | | | | | - Arushi Gulati
- University of California, San Francisco, California, USA
| | | | | | - Paul T. Hoff
- University of Michigan, Ann Arbor, Michigan, USA
| | - Oliver M.G. Hoffmann
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | - Jennifer Hsia
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Colin Huntley
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | | | - Sanjana Inala
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | | | | | | | | | | | - Meena Khan
- Ohio State University, Columbus, Ohio, USA
| | | | - Alan Kominsky
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | - Meir Kryger
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Derek J. Lam
- Oregon Health and Science University, Portland, Oregon, USA
| | | | | | | | | | | | | | - Atul Malhotra
- University of California, San Diego, California, USA
| | | | - Joachim T. Maurer
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Anna M. May
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Ron B. Mitchell
- University of Texas, Southwestern and Children’s Medical Center Dallas, Texas, USA
| | | | | | | | | | - Brandon Nokes
- University of California, San Diego, California, USA
| | | | - Allan I. Pack
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | | | | | | | | - Mark Quigg
- University of Virginia, Charlottesville, Virginia, USA
| | | | - Susan Redline
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Armand Ryden
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | | | - Firas Sbeih
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | | | | | | | | | - Jiyeon Seo
- University of California, Los Angeles, California, USA
| | - Neomi Shah
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | - Ryan J. Soose
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Erika Stephens
- University of California, San Francisco, California, USA
| | | | | | | | | | - Erica Thaler
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sritika Thapa
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Nico de Vries
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | | | - Ian D. Weir
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Josie Xu
- University of Toronto, Ontario, Canada
| | | | | | | | | | | | - Ilene M. Rosen
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Pinto ACPN, Rocha A, Pachito DV, Drager LF, Lorenzi-Filho G. Non-invasive positive pressure ventilation for central sleep apnoea in adults. Cochrane Database Syst Rev 2022; 10:CD012889. [PMID: 36278514 PMCID: PMC9590003 DOI: 10.1002/14651858.cd012889.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Central sleep apnoea (CSA) is characterised by abnormal patterns of ventilation during sleep due to a dysfunctional drive to breathe. Consequently, people with CSA may present poor sleep quality, sleep fragmentation, inattention, fatigue, daytime sleepiness, and reduced quality of life. OBJECTIVES To assess the effectiveness and safety of non-invasive positive pressure ventilation (NIPV) for the treatment of adults with CSA. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and Scopus on 6 September 2021. We applied no restrictions on language of publication. We also searched clinical trials registries for ongoing and unpublished studies, and scanned the reference lists of included studies to identify additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) reported in full text, those published as abstract only, and unpublished data. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias of the included studies using the Cochrane risk of bias tool version 1.0, and the certainty of the evidence using the GRADE approach. In the case of disagreement, a third review author was consulted. MAIN RESULTS We included 15 RCTs with a total of 1936 participants, ranging from 10 to 1325 participants. All studies had important methodological limitations. We assessed most studies (11 studies) as at high risk of bias for at least one domain, and all studies as at unclear risk of bias for at least two domains. The trials included participants aged > 18 years old, of which 70% to 100% were men, who were followed from one week to 60 months. The included studies assessed the effects of different modes of NIPV and CSA. Most participants had CSA associated with chronic heart failure. Because CSA encompasses a variety of causes and underlying clinical conditions, data were carefully analysed, and different conditions and populations were not pooled. The findings for the primary outcomes for the seven evaluated comparisons are presented below. Continuous positive airway pressure (CPAP) plus best supportive care versus best supportive care in CSA associated with chronic heart failure In the short term, CPAP plus best supportive care may reduce central apnoea hypopnoea index (AHI) (mean difference (MD) -14.60, 95% confidence interval (CI) -20.11 to -9.09; 1 study; 205 participants). However, CPAP plus best supportive care may result in little to no difference in cardiovascular mortality compared to best supportive care alone. The evidence for the effect of CPAP plus best supportive care on all-cause mortality is very uncertain. No adverse effects were observed with CPAP, and the results for adverse events in the best supportive care group were not reported. Adaptive servo ventilation (ASV) versus CPAP in CSA associated with chronic heart failure The evidence is very uncertain about the effect of ASV versus CPAP on quality of life evaluated in both the short and medium term. Data on adverse events were not reported, and it is not clear whether data were sought but not found. ASV versus bilevel ventilation in CSA associated with chronic heart failure In the short term, ASV may result in little to no difference in central AHI. No adverse events were detected with ASV, and the results for adverse events in the bilevel ventilation group were not reported. ASV plus best supportive care versus best supportive care in CSA associated with chronic heart failure In the medium term, ASV plus best supportive care may reduce AHI compared to best supportive care alone (MD -20.30, 95% CI -28.75 to -11.85; 1 study; 30 participants). In the long term, ASV plus best supportive care likely increases cardiovascular mortality compared to best supportive care (risk ratio (RR) 1.25, 95% CI 1.04, 1.49; 1 study; 1325 participants). The evidence suggests that ASV plus best supportive care may result in little to no difference in quality of life in the short, medium, and long term, and in all-cause mortality in the medium and long term. Data on adverse events were evaluated but not reported. ASV plus best supportive care versus best supportive care in CSA with acute heart failure with preserved ejection fraction Only adverse events were reported for this comparison, and no adverse events were recorded in either group. ASV versus CPAP maintenance in CPAP-induced CSA In the short term, ASV may slightly reduce central AHI (MD -4.10, 95% CI -6.67 to -1.53; 1 study; 60 participants), but may result in little to no difference in quality of life. Data on adverse events were not reported, and it is not clear whether data were sought but not found. ASV versus bilevel ventilation in CPAP-induced CSA In the short term, ASV may slightly reduce central AHI (MD -8.70, 95% CI -11.42 to -5.98; 1 study; 30 participants) compared to bilevel ventilation. Data on adverse events were not reported, and it is not clear whether data were sought but not found. AUTHORS' CONCLUSIONS CPAP plus best supportive care may reduce central AHI in people with CSA associated with chronic heart failure compared to best supportive care alone. Although ASV plus best supportive care may reduce AHI in people with CSA associated with chronic heart failure, it likely increases cardiovascular mortality in these individuals. In people with CPAP-induced CSA, ASV may slightly reduce central AHI compared to bilevel ventilation and to CPAP. In the absence of data showing a favourable impact on meaningful patient-centred outcomes and defining clinically important differences in outcomes in CSA patients, these findings need to be interpreted with caution. Considering the level of certainty of the available evidence and the heterogeneity of participants with CSA, we could draw no definitive conclusions, and further high-quality trials focusing on patient-centred outcomes, such as quality of life, quality of sleep, and longer-term survival, are needed to determine whether one mode of NIPV is better than another or than best supportive care for any particular CSA patient group.
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Affiliation(s)
- Ana Carolina Pereira Nunes Pinto
- Cochrane Brazil, Health Technology Assessment Center, São Paulo, Brazil
- Biological and Health Sciences Department, Federal University of Amapa, Amapá, Brazil
- Post-graduation program in Evidence-based Health, Department of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Aline Rocha
- Cochrane Brazil, Núcleo de Avaliação de Tecnologias em Saúde, São Paulo, Brazil
| | | | - Luciano F Drager
- Unidade de Hipertensão, Disciplina de Nefrologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
- Unidade de Hipertensão, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
- Cardiology Center, Hospital Sírio Libanes, São Paulo, Brazil
| | - Geraldo Lorenzi-Filho
- Laboratorio de Sono, Divisao de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Hoff S, Collop N. A Brief Review of Treatment of Obstructive Sleep Apnea. Respir Med 2022. [DOI: 10.1007/978-3-030-93739-3_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Treatment-emergent central sleep apnea (TECSA) is a specific form of sleep-disordered breathing, characterized by the emergence or persistence of central apneas during treatment for obstructive sleep apnea. The purpose of this review was to summarize the definition, epidemiology, potential mechanisms, clinical characteristics, and treatment of TECSA. We searched for relevant articles up to January 31, 2020, in the PubMed database. The prevalence of TECSA varied widely in different studies. The potential mechanisms leading to TECSA included ventilatory control instability, low arousal threshold, activation of lung stretch receptors, and prolonged circulation time. TECSA may be a self-limited disorder in some patients and could be resolved spontaneously over time with ongoing treatment of continuous positive airway pressure (CPAP). However, central apneas persist even with the regular CPAP therapy in some patients, and new treatment approaches such as adaptive servo-ventilation may be necessary. We concluded that several questions regarding TECSA remain, despite the findings of many studies, and it is necessary to carry out large surveys with basic scientific design and clinical trials for TECSA to clarify these irregularities. Further, it will be vital to evaluate the baseline demographic and polysomnographic data of TECSA patients more carefully and comprehensively.
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Zeineddine S, Badr MS. Treatment-Emergent Central Apnea: Physiologic Mechanisms Informing Clinical Practice. Chest 2021; 159:2449-2457. [PMID: 33497650 DOI: 10.1016/j.chest.2021.01.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 12/11/2020] [Accepted: 01/14/2021] [Indexed: 11/26/2022] Open
Abstract
The purpose of this review was to describe our management approach to patients with treatment-emergent central sleep apnea (TECSA). The emergence of central sleep apnea during positive airway pressure therapy occurs in approximately 8% of titration studies for OSA, and it has been associated with several demographic, clinical, and polysomnographic factors, as well as factors related to the titration study itself. TECSA shares similar pathophysiology with central sleep apnea. In fact, central and OSA pathophysiologic mechanisms are inextricably intertwined, with ventilatory instability and upper airway narrowing occurring in both entities. TECSA is a "dynamic" process, with spontaneous resolution with ongoing positive airway pressure therapy in most patients, persistence in some, or appearing de novo in a minority of patients. Management strategy for TECSA aims to eliminate abnormal respiratory events, stabilize sleep architecture, and improve the underlying contributing medical comorbidities. CPAP therapy remains a standard therapy for TECSA. Expectant management is appropriate given its transient nature in most cases, whereas select patients would benefit from an early switch to an alternative positive airway pressure modality. Other treatment options include supplemental oxygen and pharmacologic therapy.
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Affiliation(s)
- Salam Zeineddine
- John D. Dingell VA Medical Center, Detroit, MI; Department of Medicine, Wayne State University, Detroit, MI
| | - M Safwan Badr
- John D. Dingell VA Medical Center, Detroit, MI; Department of Medicine, Wayne State University, Detroit, MI.
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8
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Selim B, Ramar K. Sleep-Related Breathing Disorders: When CPAP Is Not Enough. Neurotherapeutics 2021; 18:81-90. [PMID: 33150546 PMCID: PMC8116389 DOI: 10.1007/s13311-020-00955-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2020] [Indexed: 02/07/2023] Open
Abstract
Three decades ago, continuous positive airway pressure (CPAP) was introduced to treat obstructive sleep apnea (OSA). Shortly after, bilevel positive airway pressure devices (BPAP) that independently adjusted inspiratory and expiratory positive airway pressure were developed to treat complex sleep-related breathing disorders unresponsive to CPAP. Based on the bilevel positive airway pressure platform (hardware) governed by propriety algorithms (software), advanced modes of noninvasive ventilation (NIV) were developed to address complex cardiorespiratory pathophysiology beyond OSA. This review summarizes key aspects of different bilevel PAP therapies (BPAP with/without backup rate, adaptive servoventilation, and volume-assured pressure support) to treat common sleep-related hypoventilation disorders, treatment-emergent central sleep apnea, and central sleep apnea syndromes.
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Affiliation(s)
- Bernardo Selim
- Pulmonary and Critical Care Division, Center for Sleep Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Kannan Ramar
- Pulmonary and Critical Care Division, Center for Sleep Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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9
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Treatment of Obstructive Sleep Apnea: Achieving Adherence to Positive Airway Pressure Treatment and Dealing with Complications. Sleep Med Clin 2020; 15:227-240. [PMID: 32386697 DOI: 10.1016/j.jsmc.2020.02.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Obstructive sleep apnea is a common and treatable condition, but therapeutic adherence is limited by numerous factors. Despite advances in positive airway pressure (PAP) technology and a multitude of effective pharmacologic and behavioral therapeutic interventions to overcome the most common barriers to PAP, adherence has not increased significantly over the past 30 years. This review aims to identify the most important factors that impact adherence, common barriers to treatment, and evidence-based treatment strategies to maximize the effectiveness of PAP treatment. Complications of PAP treatment and mitigation techniques are also discussed.
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10
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Huseini T, McArdle N, Jasper E, Kurmagadda S, Douglas J, King S, Sturdy G, Singh B. The use and effectiveness of adaptive servo ventilation in central sleep apnea: a study of consecutive sleep clinic patients. J Sleep Res 2020; 29:e13016. [PMID: 32087043 DOI: 10.1111/jsr.13016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/24/2019] [Accepted: 02/03/2020] [Indexed: 02/03/2023]
Abstract
The use of adaptive servo ventilation to treat central sleep apnea in the clinical setting is incompletely understood and could be under-utilized. We reviewed our experience of adaptive servo ventilation use in patients with central sleep apnea. This study shows the effectiveness of adaptive servo ventilation in treating patients with central sleep apnea, irrespective of a predisposing factor, as assessed during a 4-week treatment trial. Results show that adaptive servo ventilation was effective and superior to continuous positive airway pressure in controlling central sleep apnea and improving symptoms. Only a small proportion of these patients had comorbid heart failure. Early treatment with adaptive servo ventilation may improve long-term adherence to therapy. These findings highlight the utility of adaptive servo ventilation in the management of central sleep apnea.
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Affiliation(s)
- Taha Huseini
- Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Nigel McArdle
- Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia.,West Australian Sleep Disorders Research Institute, Nedlands, WA, Australia.,School of Human Sciences, University of Western Australia, Crawley, WA, Australia
| | - Emily Jasper
- Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Sasya Kurmagadda
- Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Jane Douglas
- Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Stuart King
- Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Gavin Sturdy
- Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Bhajan Singh
- Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia.,West Australian Sleep Disorders Research Institute, Nedlands, WA, Australia.,School of Human Sciences, University of Western Australia, Crawley, WA, Australia
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Randerath W, Deleanu O, Schiza S, Pepin JL. Central sleep apnoea and periodic breathing in heart failure: prognostic significance and treatment options. Eur Respir Rev 2019; 28:28/153/190084. [PMID: 31604817 PMCID: PMC9488867 DOI: 10.1183/16000617.0084-2019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 08/30/2019] [Indexed: 12/27/2022] Open
Abstract
Central sleep apnoea (CSA) including periodic breathing is prevalent in more than one-third of patients with heart failure and is highly and independently associated with poor outcomes. Optimal treatment is still debated and well-conducted studies regarding efficacy and impact on outcomes of available treatment options are limited, particularly in cardiac failure with preserved ejection fraction. While continuous positive airway pressure and oxygen reduce breathing disturbances by 50%, adaptive servoventilation (ASV) normalises breathing disturbances by to controlling the underlying mechanism of CSA. Results are contradictory regarding impact of ASV on hard outcomes. Cohorts and registry studies show survival improvement under ASV, while secondary analyses of the large SERVE-HF randomised trial showed an excess mortality in cardiac failure with reduced ejection fraction. The current priority is to understand which phenotypes of cardiac failure patients may benefit from treatment guiding individualised and personalised management.
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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
| | - Oana Deleanu
- University of Medicine and Pharmacy "Carol Davila" and Institute of Pneumology "Marius Nasta" Bucharest, Bucharest, Romania
| | - Sofia Schiza
- Sofia Schiza, University of Crete, Heraklion, Greece
| | - Jean-Louis Pepin
- Laboratoire du sommeil explorations fonctionnelle Respire, Centre Hospitalier Universitaire Grenoble, Grenoble, France
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Unilateral phrenic nerve stimulation in the therapeutical algorithm of central sleep apnoea in heart failure. Curr Opin Pulm Med 2019; 25:561-569. [PMID: 31313744 DOI: 10.1097/mcp.0000000000000606] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Central sleep apnoea (CSA) is highly prevalent in patients with heart failure and substantially impairs survival. If optimal cardiac treatment fails, alternative therapeutical options, including positive airway pressure (PAP) therapies, drugs or application of oxygen and carbon dioxide are considered to suppress CSA which interfere with the complex underlying pathophysiology. Most recently, unilateral phrenic nerve stimulation (PNS) has been studied in these patients. Therefore, there is an urgent need to critically evaluate efficacy, potential harm and positioning of PNS in current treatment algorithms. RECENT FINDINGS Data from case series and limited randomized controlled trials demonstrate the feasibility of the invasive approach and acceptable peri-interventional adverse events. PNS reduces CSA by 50%, a figure comparable with continuous PAP or oxygen. However, PNS cannot improve any comorbid upper airways obstruction. A number of fatalities due to malignant cardiac arrhythmias or other cardiac events have been reported, although the association with the therapy is unclear. SUMMARY PNS offers an additional option to the therapeutical portfolio. Intervention-related adverse events and noninvasive alternatives need clear discussion with the patient. The excess mortality in the SERVE-HF study has mainly been attributed to sudden cardiac death. Therefore, previous cardiac fatalities under PNS urge close observation in future studies as long-term data are missing.
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Herkenrath SD, Randerath WJ. More than Heart Failure: Central Sleep Apnea and Sleep-Related Hypoventilation. Respiration 2019; 98:95-110. [PMID: 31291632 DOI: 10.1159/000500728] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 05/02/2019] [Indexed: 12/29/2022] Open
Abstract
Central sleep apnea (CSA) comprises a variety of breathing patterns and clinical entities. They can be classified into 2 categories based on the partial pressure of carbon dioxide in the arterial blood. Nonhypercapnic CSA is usually characterized by a periodic breathing pattern, while hypercapnic CSA is based on hypoventilation. The latter CSA form is associated with central nervous, neuromuscular, and rib cage disorders as well as obesity and certain medication or substance intake. In contrast, nonhypercapnic CSA is typically accompanied by an overshoot of the ventilation and often associated with heart failure, cerebrovascular diseases, and stay in high altitude. CSA and hypoventilation syndromes are often considered separately, but pathophysiological aspects frequently overlap. An integrative approach helps to recognize underlying pathophysiological mechanisms and to choose adequate therapeutic strategies. Research in the last decades improved our insights; nevertheless, diagnostic tools are not always appropriately chosen to perform comprehensive sleep studies. This supports misinterpretation and misclassification of sleep disordered breathing. The purpose of this article is to highlight unresolved problems, raise awareness for different pathophysiological components and to discuss the evidence for targeted therapeutic strategies.
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Chen C, Wen T, Liao W. Nocturnal supports for patients with central sleep apnea and heart failure: a systemic review and network meta-analysis of randomized controlled trials. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:337. [PMID: 31475207 DOI: 10.21037/atm.2019.06.72] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Sleep apnea probably brings poor outcomes of chronic heart failure (CHF), and some methods show benefit to patients with heart failure (HF) and central sleep apnea (CSA). Our study based on the randomized controlled trials (RCTs) to find out the most beneficial therapy of nocturnal support to decrease the apnea hypopnea index (AHI). Methods The PubMed, and the Web of Science were used to find out the included studies. RevMan 5.3 and Stata 15.1 were performed to this systemic review and network meta-analysis. Results After searching and screening the articles, finally we included 14 articles with total 919 patients, and 4 arms [adaptive servo ventilation (ASV), continuous positive airway pressure (CPAP), oxygen treatment, control]. Compared with the control group, the therapeutic regimens did not show significant difference in AHI. Ranking the different nocturnal supports in the order of estimated probabilities of each treatment by using the network meta-analysis, the result showed that ASV was the best one (87.8%), followed by oxygen (12.2%), CPAP (0%), and control (0%). Conclusions Based on our study, the adoptive servo ventilation is probably the best choice to down the AHI in patients with HF and CSA.
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Affiliation(s)
- Chongxiang Chen
- Department of Intensive Care Unit, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Tianmeng Wen
- School of Public Health, Sun Yat-sen University, Guangzhou 510060, China
| | - Wei Liao
- Department of Intensive Care Unit, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
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16
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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]
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17
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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
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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
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Treatment of Obstructive Sleep Apnea: Achieving Adherence to Positive Airway Pressure Treatment and Dealing with Complications. Sleep Med Clin 2017; 12:551-564. [PMID: 29108610 DOI: 10.1016/j.jsmc.2017.07.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Obstructive sleep apnea is a common and treatable condition, but therapeutic adherence is limited by numerous factors. Despite advances in positive airway pressure (PAP) technology and a multitude of effective pharmacologic and behavioral therapeutic interventions to overcome the most common barriers to PAP, adherence has not increased significantly over the past 30 years. This review aims to identify the most important factors that impact adherence, common barriers to treatment, and evidence-based treatment strategies to maximize the effectiveness of PAP treatment. Complications of PAP treatment and mitigation techniques are also discussed.
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Device Therapy for Sleep-Disordered Breathing in Patients with Cardiovascular Diseases and Heart Failure. Sleep Med Clin 2017; 12:243-254. [DOI: 10.1016/j.jsmc.2017.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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20
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Randerath W, Verbraecken J, Andreas S, Arzt M, Bloch KE, Brack T, Buyse B, De Backer W, Eckert DJ, Grote L, Hagmeyer L, Hedner J, Jennum P, La Rovere MT, Miltz C, McNicholas WT, Montserrat J, Naughton M, Pepin JL, Pevernagie D, Sanner B, Testelmans D, Tonia T, Vrijsen B, Wijkstra P, Levy P. Definition, discrimination, diagnosis and treatment of central breathing disturbances during sleep. Eur Respir J 2016; 49:13993003.00959-2016. [DOI: 10.1183/13993003.00959-2016] [Citation(s) in RCA: 169] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 08/25/2016] [Indexed: 02/07/2023]
Abstract
The complexity of central breathing disturbances during sleep has become increasingly obvious. They present as central sleep apnoeas (CSAs) and hypopnoeas, periodic breathing with apnoeas, or irregular breathing in patients with cardiovascular, other internal or neurological disorders, and can emerge under positive airway pressure treatment or opioid use, or at high altitude. As yet, there is insufficient knowledge on the clinical features, pathophysiological background and consecutive algorithms for stepped-care treatment. Most recently, it has been discussed intensively if CSA in heart failure is a “marker” of disease severity or a “mediator” of disease progression, and if and which type of positive airway pressure therapy is indicated. In addition, disturbances of respiratory drive or the translation of central impulses may result in hypoventilation, associated with cerebral or neuromuscular diseases, or severe diseases of lung or thorax. These statements report the results of an European Respiratory Society Task Force addressing actual diagnostic and therapeutic standards. The statements are based on a systematic review of the literature and a systematic two-step decision process. Although the Task Force does not make recommendations, it describes its current practice of treatment of CSA in heart failure and hypoventilation.
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S3-Leitlinie Nicht erholsamer Schlaf/Schlafstörungen – Kapitel „Schlafbezogene Atmungsstörungen“. SOMNOLOGIE 2016. [DOI: 10.1007/s11818-016-0093-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Liu F, Wang X. Diagnosis and treatment of epilepsy and sleep apnea comorbidity. Expert Rev Neurother 2016; 17:475-485. [PMID: 27866428 DOI: 10.1080/14737175.2017.1262259] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Feng Liu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China
| | - Xuefeng Wang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China
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Selim B, Ramar K. Advanced positive airway pressure modes: adaptive servo ventilation and volume assured pressure support. Expert Rev Med Devices 2016; 13:839-51. [PMID: 27478974 DOI: 10.1080/17434440.2016.1218759] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Volume assured pressure support (VAPS) and adaptive servo ventilation (ASV) are non-invasive positive airway pressure (PAP) modes with sophisticated negative feedback control systems (servomechanism), having the capability to self-adjust in real time its respiratory controlled variables to patient's respiratory fluctuations. However, the widespread use of VAPS and ASV is limited by scant clinical experience, high costs, and the incomplete understanding of propriety algorithmic differences in devices' response to patient's respiratory changes. Hence, we will review and highlight similarities and differences in technical aspects, control algorithms, and settings of each mode, focusing on the literature search published in this area. AREAS COVERED One hundred twenty relevant articles were identified by Scopus, PubMed, and Embase databases from January 2010 to 2016, using a combination of MeSH terms and keywords. Articles were further supplemented by pearling. Recommendations were based on the literature review and the authors' expertise in this area. Expert commentary: ASV and VAPS differ in their respiratory targets and response to a respiratory fluctuation. The VAPS mode targets a more consistent minute ventilation, being recommended in the treatment of sleep related hypoventilation disorders, while ASV mode attempts to provide a more steady breathing airflow pattern, treating successfully most central sleep apnea syndromes.
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Affiliation(s)
- Bernardo Selim
- a Division of Pulmonary and Critical Care Medicine , Mayo Clinic , Rochester , MN , USA
| | - Kannan Ramar
- a Division of Pulmonary and Critical Care Medicine , Mayo Clinic , Rochester , MN , USA
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Randerath W, Javaheri S. Sleep-Disordered Breathing in Patients with Heart Failure. CURRENT SLEEP MEDICINE REPORTS 2016. [DOI: 10.1007/s40675-016-0047-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Nigam G, Riaz M, Schotland HM, Eiser AS. Continuous positive airway pressure-emergent protracted central apneas with profound oxygen desaturation. Am J Respir Crit Care Med 2016; 192:e49-50. [PMID: 26426793 DOI: 10.1164/rccm.201502-0301im] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | - Helena M Schotland
- 1 Sleep Disorders Center.,2 Division of Pulmonary and Critical Care Medicine
| | - Alan S Eiser
- 1 Sleep Disorders Center.,3 Department of Neurology, and.,4 Department of Psychiatry, University of Michigan School of Medicine, Ann Arbor, Michigan
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Moro M, Gannon K, Lovell K, Merlino M, Mojica J, Bianchi MT. Clinical predictors of central sleep apnea evoked by positive airway pressure titration. Nat Sci Sleep 2016; 8:259-66. [PMID: 27555802 PMCID: PMC4968988 DOI: 10.2147/nss.s110032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
PURPOSE Treatment-emergent central sleep apnea (TECSA), also called complex apnea, occurs in 5%-15% of sleep apnea patients during positive airway pressure (PAP) therapy, but the clinical predictors are not well understood. The goal of this study was to explore possible predictors in a clinical sleep laboratory cohort, which may highlight those at risk during clinical management. METHODS We retrospectively analyzed 728 patients who underwent PAP titration (n=422 split-night; n=306 two-night). Demographics and self-reported medical comorbidities, medications, and behaviors as well as standard physiological parameters from the polysomnography (PSG) data were analyzed. We used regression analysis to assess predictors of binary presence or absence of central apnea index (CAI) ≥5 during split-night PSG (SN-PSG) versus full-night PSG (FN-PSG) titrations. RESULTS CAI ≥5 was present in 24.2% of SN-PSG and 11.4% of FN-PSG patients during titration. Male sex, maximum continuous positive airway pressure, and use of bilevel positive airway pressure were predictors of TECSA, and rapid eye movement dominance was a negative predictor, for both SN-PSG and FN-PSG patients. Self-reported narcotics were a positive predictor of TECSA, and the time spent in stage N2 sleep was a negative predictor only for SN-PSG patients. Self-reported history of stroke and the CAI during the diagnostic recording predicted TECSA only for FN-PSG patients. CONCLUSION Clinical predictors of treatment-evoked central apnea spanned demographic, medical history, sleep physiology, and titration factors. Improved predictive models may be increasingly important as diagnostic and therapeutic modalities move away from the laboratory setting, even as PSG remains the gold standard for characterizing primary central apnea and TECSA.
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Affiliation(s)
| | | | | | | | - James Mojica
- Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Matt T Bianchi
- Neurology Department; Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
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28
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Cao M, Cardell CY, Willes L, Mendoza J, Benjafield A, Kushida C. A novel adaptive servoventilation (ASVAuto) for the treatment of central sleep apnea associated with chronic use of opioids. J Clin Sleep Med 2014; 10:855-61. [PMID: 25126031 DOI: 10.5664/jcsm.3954] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES To compare the efficacy and patient comfort of a new mode of minute ventilation-targeted adaptive servoventilation (ASVAuto) with auto-titrating expiratory positive airway pressure (EPAP) versus bilevel with back-up respiratory rate (bilevel-ST) in patients with central sleep apnea (CSA) associated with chronic use of opioid medications. METHODS Prospective, randomized, crossover polysomnography (PSG) study. Eighteen consecutive patients (age ≥ 18 years) who had been receiving opioid therapy (≥ 6 months), and had sleep disordered breathing with CSA (central apnea index [CAI] ≥ 5) diagnosed during an overnight sleep study or positive airway pressure (PAP) titration were enrolled to undergo 2 PSG studies-one with ASVAuto and one with bilevel-ST. Patients completed 2 questionnaires after each PSG; Morning After Patient Satisfaction Questionnaire and PAP Comfort Questionnaire. RESULTS Patients had a mean age of 52.9 ± 15.3 years. PSG prior to randomization showed an apnea hypopnea index (AHI) of 50.3 ± 22.2 and CAI of 13.0 ± 18.7. Titration with ASVAuto versus bilevel-ST showed that there were significant differences with respect to AHI and CAI. The AHI and CAI were significantly lower on ASVAuto than bilevel-ST (2.5 ± 3.5 versus 16.3 ± 20.9 [p = 0.0005], and 0.4 ± 0.8 versus 9.4 ± 18.8 [p = 0.0002], respectively). Respiratory parameters were normalized in 83.3% of patients on ASVAuto versus 33.3% on bilevel-ST. Patients felt more awake and alert on ASVAuto than bilevel-ST based on scores from Morning After Patient Satisfaction Questionnaire (p = 0.0337). CONCLUSIONS The ASVAuto was significantly more effective than bilevel-ST for the treatment of CSA associated with chronic opioid use.
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Affiliation(s)
- Michelle Cao
- Stanford Sleep Medicine, Stanford University School of Medicine, Redwood City, CA
| | - Chia-Yu Cardell
- Stanford Sleep Medicine, Stanford University School of Medicine, Redwood City, CA
| | | | - June Mendoza
- ResMed Science Center, ResMed Corp., San Diego, CA
| | | | - Clete Kushida
- Stanford Sleep Medicine, Stanford University School of Medicine, Redwood City, CA
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Abstract
After the institution of positive-pressure ventilation, the use of noninvasive ventilation (NIV) through an interface substantially increased. The first technique was continuous positive airway pressure; but, after the introduction of pressure support ventilation at the end of the 20th century, this became the main modality. Both techniques, and some others that have been recently introduced and which integrate some technological innovations, have extensively demonstrated a faster improvement of acute respiratory failure in different patient populations, avoiding endotracheal intubation and facilitating the release of conventional invasive mechanical ventilation. In acute settings, NIV is currently the first-line treatment for moderate-to-severe chronic obstructive pulmonary disease exacerbation as well as for acute cardiogenic pulmonary edema and should be considered in immunocompromised patients with acute respiratory insufficiency, in difficult weaning, and in the prevention of postextubation failure. Alternatively, it can also be used in the postoperative period and in cases of pneumonia and asthma or as a palliative treatment. NIV is currently used in a wide range of acute settings, such as critical care and emergency departments, hospital wards, palliative or pediatric units, and in pre-hospital care. It is also used as a home care therapy in patients with chronic pulmonary or sleep disorders. The appropriate selection of patients and the adaptation to the technique are the keys to success. This review essentially analyzes the evidence of benefits of NIV in different populations with acute respiratory failure and describes the main modalities, new devices, and some practical aspects of the use of this technique.
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Affiliation(s)
- Arantxa Mas
- Critical Care Department, Consorci Sanitari Integral (CSI), Hospital Sant Joan Despí Moisès Broggi and Hospital General de l’Hospitalet, University of Barcelona, Barcelona, Spain
| | - Josep Masip
- Critical Care Department, Consorci Sanitari Integral (CSI), Hospital Sant Joan Despí Moisès Broggi and Hospital General de l’Hospitalet, University of Barcelona, Barcelona, Spain
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Morgenthaler TI, Kuzniar TJ, Wolfe LF, Willes L, McLain WC, Goldberg R. The complex sleep apnea resolution study: a prospective randomized controlled trial of continuous positive airway pressure versus adaptive servoventilation therapy. Sleep 2014; 37:927-34. [PMID: 24790271 DOI: 10.5665/sleep.3662] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION Prior studies show that adaptive servoventilation (ASV) is initially more effective than continuous positive airway pressure (CPAP) for patients with complex sleep apnea syndrome (CompSAS), but choosing therapies has been controversial because residual central breathing events may resolve over time in many patients receiving chronic CPAP therapy. We conducted a multicenter, randomized, prospective trial comparing clinical and polysomnographic outcomes over prolonged treatment of patients with CompSAS, with CPAP versus ASV. METHODS Qualifying participants meeting criteria for CompSAS were randomized to optimized CPAP or ASV treatment. Clinical and polysomnographic data were obtained at baseline and after 90 days of therapy. RESULTS We randomized 66 participants (33 to each treatment). At baseline, the diagnostic apnea-hypopnea index (AHI) was 37.7 ± 27.8 (central apnea index [CAI] = 3.2 ± 5.8) and best CPAP AHI was 37.0 ± 24.9 (CAI 29.7 ± 25.0). After second-night treatment titration, the AHI was 4.7 ± 8.1 (CAI = 1.1 ± 3.7) on ASV and 14.1 ± 20.7 (CAI = 8.8 ± 16.3) on CPAP (P ≤ 0.0003). At 90 days, the ASV versus CPAP AHI was 4.4 ± 9.6 versus 9.9 ± 11.1 (P = 0.0024) and CAI was 0.7 ± 3.4 versus 4.8 ± 6.4 (P < 0.0001), respectively. In the intention-to-treat analysis, success (AHI < 10) at 90 days of therapy was achieved in 89.7% versus 64.5% of participants treated with ASV and CPAP, respectively (P = 0.0214). Compliance and changes in Epworth Sleepiness Scale and Sleep Apnea Quality of Life Index were not significantly different between treatment groups. CONCLUSION Adaptive servoventilation (ASV) was more reliably effective than CPAP in relieving complex sleep apnea syndrome. While two thirds of participants experienced success with CPAP, approximately 90% experienced success with ASV. Because both methods produced similar symptomatic changes, it is unclear if this polysomnographic effectiveness may translate into other desired outcomes. CLINICAL TRIALS Clinicaltrials.Gov NCT00915499.
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Affiliation(s)
- Timothy I Morgenthaler
- Mayo Clinic Center for Sleep Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | | | - Lisa F Wolfe
- Northwestern University Feinberg School of Medicine, Chicago, IL
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Complex sleep apnea syndrome. SLEEP DISORDERS 2014; 2014:798487. [PMID: 24693440 PMCID: PMC3945285 DOI: 10.1155/2014/798487] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 11/10/2013] [Accepted: 11/23/2013] [Indexed: 12/16/2022]
Abstract
Complex sleep apnea is the term used to describe a form of sleep disordered breathing in which repeated central apneas (>5/hour) persist or emerge when obstructive events are extinguished with positive airway pressure (PAP) and for which there is not a clear cause for the central apneas such as narcotics or systolic heart failure. The driving forces in the pathophysiology are felt to be ventilator instability associated oscillation in PaCO2 arterial partial pressure of Carbon Dioxide, continuous cositive airway pressure (CPAP) related increased CO2 carbon dioxide elimination, and activation of airway and pulmonary stretch receptors triggering these central apneas. The prevalence ranges from 0.56% to 18% with no clear predictive characteristics as compared to simple obstructive sleep apnea. Prognosis is similar to obstructive sleep apnea. The central apnea component in most patients on followup using CPAP therap, has resolved. For those with continued central apneas on simple CPAP therapy, other treatment options include bilevel PAP, adaptive servoventilation, permissive flow limitation and/or drugs.
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Weaver TE, Calik MW, Farabi SS, Fink AM, Galang-Boquiren MT, Kapella MC, Prasad B, Carley DW. Innovative treatments for adults with obstructive sleep apnea. Nat Sci Sleep 2014; 6:137-47. [PMID: 25429246 PMCID: PMC4242689 DOI: 10.2147/nss.s46818] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Obstructive sleep apnea (OSA) affects one in five adult males and is associated with significant comorbidity, cognitive impairment, excessive daytime sleepiness, and reduced quality of life. For over 25 years, the primary treatment has been continuous positive airway pressure, which introduces a column of air that serves as a pneumatic splint for the upper airway, preventing the airway collapse that is the physiologic definition of this syndrome. However, issues with patient tolerance and unacceptable levels of treatment adherence motivated the exploration of other potential treatments. With greater understanding of the physiologic mechanisms associated with OSA, novel interventions have emerged in the last 5 years. The purpose of this article is to describe new treatments for OSA and associated complex sleep apnea. New approaches to complex sleep apnea have included adaptive servoventilation. There is increased literature on the contribution of behavioral interventions to improve adherence with continuous positive airway pressure that have proven quite effective. New non-surgical treatments include oral pressure devices, improved mandibular advancement devices, nasal expiratory positive airway pressure, and newer approaches to positional therapy. Recent innovations in surgical interventions have included laser-assisted uvulopalatoplasty, radiofrequency ablation, palatal implants, and electrical stimulation of the upper airway muscles. No drugs have been approved to treat OSA, but potential drug therapies have centered on increasing ventilatory drive, altering the arousal threshold, modifying loop gain (a dimensionless value quantifying the stability of the ventilatory control system), or preventing airway collapse by affecting the surface tension. An emerging approach is the application of cannabinoids to increase upper airway tone.
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Affiliation(s)
- Terri E Weaver
- Biobehavioral Health Science Department, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA ; Center for Narcolepsy, Sleep and Health, University of Illinois at Chicago College of Nursing, Chicago, IL, USA
| | - Michael W Calik
- Biobehavioral Health Science Department, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA ; Center for Narcolepsy, Sleep and Health, University of Illinois at Chicago College of Nursing, Chicago, IL, USA
| | - Sarah S Farabi
- Biobehavioral Health Science Department, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA ; Center for Narcolepsy, Sleep and Health, University of Illinois at Chicago College of Nursing, Chicago, IL, USA
| | - Anne M Fink
- Biobehavioral Health Science Department, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA ; Center for Narcolepsy, Sleep and Health, University of Illinois at Chicago College of Nursing, Chicago, IL, USA
| | - Maria T Galang-Boquiren
- Center for Narcolepsy, Sleep and Health, University of Illinois at Chicago College of Nursing, Chicago, IL, USA ; Department of Orthodontics, University of Illinois at Chicago College of Dentistry, Chicago, IL, USA
| | - Mary C Kapella
- Biobehavioral Health Science Department, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA ; Center for Narcolepsy, Sleep and Health, University of Illinois at Chicago College of Nursing, Chicago, IL, USA
| | - Bharati Prasad
- Center for Narcolepsy, Sleep and Health, University of Illinois at Chicago College of Nursing, Chicago, IL, USA ; Sleep Center, Department of Medicine, University of Illinois at Chicago College of Medicine, Chicago, IL, USA
| | - David W Carley
- Biobehavioral Health Science Department, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA ; Center for Narcolepsy, Sleep and Health, University of Illinois at Chicago College of Nursing, Chicago, IL, USA
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Abstract
OPINION STATEMENT Complex sleep apnea currently refers to the emergence and persistence of central apneas and hypopneas following the application of positive airway pressure therapy in patients with obstructive sleep apnea. However, this narrow definition is an "outcome" and does not capture the spectrum of pathological activation of the respiratory chemoreflex in sleep apnea. The International Classification of Sleep Disorders - 3rd edition recognizes the phenomenon of Treatment-Related Central Sleep Apnea, but the phenotype is usually evident prior to onset of therapy. The key polysomnographic characteristics of chemoreflex modulated and mediated sleep apnea are nonrapid eye movement (NREM) dominance of respiratory events, short (<30 seconds) or long (>60 seconds) cycle time with a self-similar metronomic timing, and spontaneous improvement during rapid eye movement (REM) sleep. Thus, the majority of chemoreflex effects go unrecognized due to the bias toward obstructive sleep apnea's current scoring criteria. Any treatment of apparently obstructive sleep apnea, including surgery and oral appliances, can expose chemoreflex-driven instabilities. As both sleep fragmentation and a narrow CO2 reserve or increased loop gain drive the disease, sedatives (to induce longer periods of stable NREM sleep and reduce the destabilizing effects of arousals in NREM sleep) and CO2-based stabilization approaches are logical. Adaptive ventilation reduces mean hyperventilation yet can induce ventilator-patient desynchrony, while enhanced expiratory rebreathing space (EERS, dead space during positive pressure therapy) and CO2 manipulation directly stabilize respiratory control by moving CO2 above the apnea threshold. Carbonic anhydrase inhibition can provide further adjunctive benefits. Novel pharmacological approaches may target mediators of carotid body hypoxic sensitization, such as the balance between gas neurotransmitters. In complex apnea patients, single mode therapy is unlikely to be successful, and the power of multi-modality therapy should be harnessed for optimal outcomes.
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Edwards BA, Malhotra A, Sands SA. Adapting our approach to treatment-emergent central sleep apnea. Sleep 2013; 36:1121-2. [PMID: 23904668 DOI: 10.5665/sleep.2862] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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