Polysomnography in stable COPD under non-invasive ventilation to reduce patient-ventilator asynchrony and morning breathlessness

Background: Stable severe chronic obstructive pulmonary disease (COPD) patients with chronic hypercapnic respiratory failure treated by nocturnal bi-level positive pressure non-invasive ventilation (NIV) may experience severe morning deventilation dyspnea. We hypothesised that in these patients, progressive hyperinflation, resulting from inappropriate ventilator settings, leads to patient-ventilator asynchrony (PVA) with a high rate of unrewarded inspiratory efforts and morning discomfort. Methods: Polysomnography (PSG), diaphragm electromyogram and transcutaneous capnography (PtcCO2) under NIV during two consecutive nights using baseline ventilator settings on the first night, then, during the second night, adjustment of ventilator parameters under PSG with assessment of impact of settings changes on sleep, patient-ventilator synchronisation, morning arterial blood gases and morning dyspnea. Results: Eight patients (61 ± 8years, FEV1 30 ± 8% predicted, residual volume 210 ± 30% predicted) were included. In all patients, pressure support was decreased during setting adjustments, as well as tidal volume, while respiratory rate increased without any deleterious effect on nocturnal PtcCO2 or morning PaCO2. PVA index, initially high (40 ± 30%) during the baseline night, decreased significantly after adjusting ventilator settings (p = 0.0009), as well as subjective perception of PVA leaks, and morning dyspnea while quality of sleep improved. Conclusion: The subgroup of COPD patients treated by home NIV, who present marked deventilation dyspnea and unrewarded efforts may benefit from adjustment of ventilator settings under PSG or polygraph

Determination of therapeutic continuous positive airway pressure for obstructive sleep apnea using automatic titration: promises not fulfilled

Criticism of auto-PAP machine

Sleep apnoea syndrome: the health economics point of view.

This review analyses the available literature on the economic aspects of obstructive sleep apnoea, including the indirect medical costs, the indirect nonmedical costs, the direct costs of diagnosing and treating the disease, and the utilities as perceived by patients. The philosophical context of health economics is also considered. The literature available on the economic aspects of obstructive sleep apnoea is scarce, and frequently incomplete, so that only tentative conclusions can be reached. Obstructive sleep apnoea seems to lead to measurable (about two-fold) increases in indirect medical costs. Moreover, this excess cost seems to be reduced in the first years following the institution of treatment with nasal continuous positive airway pressure (nCPAP). There are also indirect nonmedical costs linked to the disease, for example traffic, domestic and workplace accidents. The exact extent of these costs is, however, impossible to ascertion from the available literature. Cost/utility analysis has shown full-night polysomnography to be the diagnostic approach with the higher cost/utility ratio, because diagnostic errors (greater with other approaches) carry a disproportionate weight. The cost of treating the disease has not been thoroughly assessed but appears as quite reasonable, and certainly not excessive. Finally, one study has shown in patients with severe sleep apnoea that treatment with nCPAP has a favourable effect when measured as quality adjusted life years. It is concluded that obstructive sleep apnoea leads to an excess in health-related expenditure, that treatment with nasal continuous positive airway pressure reduces this excess cost and thus makes sense in economic terms, and that patients believe nasal continuous positive airway pressure treatment to be worth considering for economic reasons. It is further concluded that medical decisions should be guided by medical (not economic) considerations, even if it is acknowledged that, for the time being, economic analysis is necessary to to convince health managers that obstructive sleep apnoea is also worth considering from the economic point of view

Assessment of Uvulopalatopharyngoplasty for the Treatment of Sleep Apnea Syndrome

Uvulopalatopharyngoplasty (UPPP) consists in the surgical removal of the uvula, part of the muscular portion of the soft palate and redundant palatal and pillar mucosa, and the tonsils. Since 1981, UPPP has been proposed for the treatment of sleep apnea syndrome. Polysomnographic studies have shown that in about half of the patients submitted to UPPP there is a 50% or greater reduction in apnea index. Attempts to identify presurgically those patients more likely to benefit from UPPP have yielded inconsistent results. Limited retrospective follow-up data suggest that UPPP does not modify the increased mortality associated with moderate and severe sleep apnea syndrome. Patients submitted to UPPP report subjective improvement, irrespective of the objective polysomnographic postsurgical results. It is suggested that polysomnographic evaluation of UPPP results should be mandatory; that any patient with 20 or more apnea/hypopneas per hour of sleep or sleep fragmentation after UPPP should be considered a treatment failure and be offered alternative therapy; and that UPPP should be performed only as part of prospective clinical trials including long-term follow-up