Obesity hypoventilation syndrome treated with non-invasive ventilation:Is a switch to CPAP therapy feasible?

Background and objective: Obesity hypoventilation syndrome (OHS) can be treated with either continuous positive airway pressure (CPAP) or non-invasive ventilation (NIV) therapy; the device choice has important economic and operational implications. Methods: This multicentre interventional trial investigated the safety and short-term efficacy of switching stable OHS patients who were on successful NIV therapy for ≥3 months to CPAP therapy. Patients underwent an autotitrating CPAP night under polysomnography (PSG); if the ensuing parameters were acceptable, they were sent home on a fixed CPAP for a 4–6-week period. It was hypothesized that blood gas analysis, PSG parameters and lung function tests would remain unchanged. Results: A total of 42 OHS patients were recruited, of whom 37 patients were switched to CPAP therapy. All patients had a history of severe obstructive sleep apnoea syndrome; chronic obstructive pulmonary disease (COPD) (Global Initiative for Obstructive Lung Disease (GOLD) I/II) was present in 52%. Regarding the primary outcome, 30 of 42 patients (71%, 95% CI: 55–84%) maintained daytime partial pressure of carbon dioxide (PaCO2) levels ≤45 mm Hg after the home CPAP period. There was no further impairment in quality of life, sleep parameters or lung function. Interestingly, 24 patients (65%) preferred CPAP as their long-term therapy, despite the high pressure levels used (mean: 13.8 ± 1.8 mbar). After the CPAP period, 7 of 37 patients were categorized as CPAP failure, albeit only due to mild hypercapnia (mean: 47.9 ± 2.7 mm Hg). Conclusion: It is feasible to switch most stable OHS patients from NIV to CPAP therapy, a step that could significantly reduce health-related costs. The auto-adjusted CPAP device, used in combination with the analysis of the PSG and capnometry, is a valid titration method in OHS patients

High-intensity non-invasive positive pressure ventilation for stable hypercapnic COPD

Background: The objective of the present analysis is to describe the outcomes of high-intensity non-invasive positive pressure ventilation (NPPV) aimed at maximally decreasing PaCO2 as an alternative to conventional NPPV with lower ventilator settings in stable hypercapnic COPD patients. Methods: Physiological parameters, exacerbation rates and long-term survival were assessed in 73 COPD patients (mean FEV1 30&#177;12 %predicted) who were established on high-intensity NPPV due to chronic hypercapnic respiratory failure between March 1997 and May 2006. Results: Controlled NPPV with breathing frequencies of 21&#177;3 breath/min and mean inspiratory/expiratory positive airway pressures of 28&#177;5/5&#177;1 cmH2O led to significant improvements in blood gases, lung function and hematocrit after two months. Only sixteen patients (22%) required hospitalisation due to exacerbation during the first year, with anaemia increasing the risk for exacerbation. Two- and five-year survival rates of all patients were 82% and 58%, respectively. The five year survival rate was 32% and 83% in patients with low (&#8804;39%) and high (&#8805;55%) hematocrit, respectively. Conclusion: High-intensity NPPV improves blood gases, lung function and hematocrit, and is also associated with low exacerbation rates and a favourable long-term outcome. The current report strongly emphasises the need for randomised controlled trials evaluating the role of high-intensity NPPV in stable hypercapnic COPD patients.</p

The role of NIV in chronic hypercapnic COPD following an acute exacerbation:the importance of patient selection?

Recently, clear benefits have been shown from long-term noninvasive ventilation (NIV) in stable chronic obstructive pulmonary disease (COPD) patients with chronic hypercapnic respiratory failure. In our opinion, these benefits are confirmed and nocturnal NIV using sufficiently high inspiratory pressures should be considered in COPD patients with chronic hypercapnic respiratory failure in stable disease, preferably combined with pulmonary rehabilitation. In contrast, clear benefits from (continuing) NIV at home after an exacerbation in patients who remain hypercapnic have not been shown. In this review we will discuss the results of five trials investigating the use of home nocturnal NIV in patients with prolonged hypercapnia after a COPD exacerbation with acute hypercapnic respiratory failure. Although some uncontrolled trials might have shown some benefits of this therapy, the largest randomized controlled trial did not show benefits in terms of hospital readmission or death. However, further studies are necessary to select the patients that optimally benefit, select the right moment to initiate home NIV, select the optimal ventilatory settings, and to choose optimal follow up programmes. Furthermore, there is insufficient knowledge about the optimal ventilatory settings in the post-exacerbation period. Finally, we are not well informed about exact reasons for readmission in patients on NIV, the course of the exacerbation and the treatment instituted. A careful follow up might probably be necessary to prevent deterioration on NIV early

Advanced Bionics' HiRes-Modus bei Kleinstkindern

Einleitung : Clarion-Implantate bei Kindern wurden überwiegend mit der Sprachverarbeitungs-strategie SAS (Simultanious Analogue Stimulation) programmiert. Nunmehr steht als Alternative die HiRes (High Resolution)-Strategie (sehr hohe Stimulationsrate) zur Verfügung.Design : Prospektive klinische Anwendungsbeobachtung unter Einbeziehung einer bestehenden SAS-KontrollgruppeMethode : Ausgesprochen erfolgreiche Versuche mit HiRes bei CI-versorgten Erwachsenen waren die Vorraussetzung für einen Beginn mit HiRes auch bei Kleinstkindern. Die HiRes-Gruppe umfasste 9 Kinder (durchschnittliches Implantationsalter ca. 1,5 Jahre). Die SAS-Kontrollgruppe wies 8 Kinder auf (durchschnittliches Versorgungsalter ca. 2,7 Jahre). Der Verlauf der Hör-Sprachentwicklung wurde mittels adaptierter MAIS- und MUSS-Fragebögen prä- sowie bisher postoperativ nach 3 und 6 Monaten dokumentiert.Ergebnisse : Sowohl MAIS- als auch MUSS-Resultate der HiRes-Gruppe liegen zunächst etwa gleichauf mit der SAS-Gruppe; nach 6 Monaten jedoch zeigt die HiRes-Gruppe deutlich bessere Ergebnisse im MAIS-Fragebogen, aber schlechtere im MUSS. Unbedingt zu berücksichtigen ist, dass das Implantationsalter der HiRes-Gruppe durchschnittlich 1,2 Jahre unter dem der SAS-Gruppe liegt. Resultate deutlich späterer Testzeitpunkte werden besonders zu beachten sein, wenn dem Einfluss des individuellen Testalters weniger Bedeutung zukommt.Zusammenfassung : Die bisher vorliegenden, sehr vielversprechenden Erfahrungen und Resultate erlauben die HiRes-Programmierung als Standardprozedur auch bei Kleinstkindern. Die Programmiersoftware ist sehr stabil und einfach zu bedienen