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

Treatment of Cheyne–Stokes respiration with adaptive servoventilation—analysis of patients with regard to therapy restriction

Purpose!#!The SERVE-HF study revealed no benefit of adaptive servoventilation (ASV) versus guideline-based medical treatment in patients with symptomatic heart failure, an ejection fraction (EF) ≤45% and a predominance of central events (apnoea-hypopnea Index [AHI] > 15/h). Because both all-cause and cardiovascular mortality were higher in the ASV group, an EF ≤ 45% in combination with AHI 15/h, central apnoea-hyponoea index [CAHI/AHI] > 50% and central apnoea index [CAI] > 10/h were subsequently listed as contraindications for ASV. The intention of our study was to analyse the clinical relevance of this limitation.!##!Methods!#!Data were analysed retrospectively for patients treated with ASV who received follow-up echocardiography to identify contraindications for ASV.!##!Results!#!Echocardiography was conducted in 23 patients. The echocardiogram was normal in 10 cases, a left ventricular hypertrophy with normal EF was found in 8 patients, there was an EF 45-50% in 2 cases and a valvular aortic stenosis (grade II) with normal EF was found in 1 case. EF <45% was present in just 2 cases, and only 1 of these patients also had more than 50% central events in the diagnostic night.!##!Conclusion!#!The population typically treated with ASV is entirely different from the study population in SERVE-HF, as nearly half of the patients treated with ASV showed a normal echocardiogram. Thus, the modified indication for ASV has little impact on the majority of treated patients. The current pathomechanistic hypothesis of central apnoea must be reviewed

Effects of respiratory muscle training (RMT) in patients with mild to moderate obstructive sleep apnea (OSA)

Purpose Different forms of training focusing on the muscles of the upper airways showed limited effects on obstructive sleep apnea (OSA) and/or snoring. We investigated the effect of generalized respiratory muscle training (RMT) in lean patients with mild to moderate OSA. Methods Nine male subjects (52.0 +/- 10.8 years, BMI 29.1 +/- 2.1 kg/m(2)) with obstructive sleep apnea (apneahypopnea index (AHI) 9-29) participated in an open, singlearm pilot study. After a 1-week build-up phase, patients underwent 4 weeks of normocapnic hyperpnea RMT five times a week for 30 min each. The initial and final measurements comprised polysomnography, pulmonary function tests, Epworth sleepiness scale (ESS), and SF-36 questionnaire (quality of life (QoL) self-assessment). The investigational site was a university-affiliated hospital for pulmonary diseases and sleep medicine, Solingen/Germany. Results Patients trained effectively, seen by a significant (p < 0.01) increase of breathing frequency (23.3 +/- 1.5/min vs. 30.6 +/- 2.9 / min) and minute volume (81.2 +/- 13.7 L vs. 109.1 +/- 21.9 L). AHI, snoring and ESS remained unchanged after training. QoL as measured by SF-36 significantly (p < 0.05) improved after the training in the subscales Bbodily pain'' (79 +/- 21 vs. 90 +/- 12) and Bchange of health'' (3.1 +/- 0.3 vs. 2.4 +/- 0.5). Conclusions There is no evidence that AHI, pulmonary function or daytime sleepiness are affected by 5 weeks of RMT. Nevertheless, there is an improvement of parameters of quality of life

Effects of continuous positive airway pressure therapy on daytime and nighttime arterial blood pressure in patients with severe obstructive sleep apnea and endothelial dysfunction

Purpose A nocturnal non-dipping or rise in blood pressure (BP) is associated with poor cardiovascular outcome. This study aimed to test whether continuous positive airway pressure (CPAP) therapy can reduce nocturnal BP and normalize the 24-h BP profile in patients with severe obstructive sleep apnea (OSA) and erectile dysfunction as a surrogate for endothelial dysfunction (ED). Patients and methods Eighteen consecutive patients with OSA and ED on stable antihypertensive medication (age 55.8 +/- 9.5 years, body mass index 35.5 +/- 3.8 kg/m(2), apnea-hypopnoea index 66.1 +/- 27.4/h) were treated with CPAP for 6 months (average daily use 5.8 +/- 2.3 h). Twenty-four hour BP recordings were performed using a portable monitoring device. Rising was defined as an increase, whereas non-dipping was defined as a fall in nocturnal BP of less than 10% compared to daytime values. Serum noradrenaline levels as markers of sympathetic activity were measured at baseline and at 6 month follow up. Results Compared to baseline, nocturnal systolic and diastolic BP were significantly reduced after CPAP therapy (128.5 +/- 14 to 122.9 +/- 11 mmHg,p = 0.036; 76.2 +/- 9 to 70.5 +/- 5 mmHg,p = 0.007). The frequency of non-dipping and rising nocturnal systolic BP, as well as mean nocturnal heart rate, was reduced after CPAP treatment (73 to 27%,p = 0.039;20 to 7%,p = 0.625; from 81.5 +/- 10 to 74.8 +/- 8 beats per minutep = 0.043). Serum levels of noradrenaline were significantly lower after CPAP therapy (398 +/- 195 ng/l vs. 303 +/- 135 ng/l,p = 0.032). Conclusion In patients with severe OSA and clinically apparent ED, CPAP therapy was associated with a decrease in nocturnal BP and serum noradrenaline levels, as well as a normalization of the 24-h BP profile

Hypoglossal nerve stimulation for obstructive sleep apnea: updated position paper of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery

Since the first statement of the German Society of Oto-Rhino-Laryngology, hypoglossal nerve stimulation (HNS) is meanwhile an established treatment option for obstructive sleep apnea (OSA). There are three HNS systems available in Germany which differ in their technical details of the underlying comparable basic principle. For the unilateral HNS with respiratory sensing, several comparative studies, high-volume register analysis and long-term reports exist. The continuous HNS without respiratory sensing does not require a sleep endoscopy for indication. For the bilateral continuous HNS as the single partially implantable device, a feasibility study exists. For indication, the assessment of positive airway pressure failure by sleep medicine is crucial, and the decision for HNS should be made in discussion of other treatment options for at least moderate OSA. The implantation center holds primarily responsibility among the interdisciplinary sleep team and is primary contact for the patient in problems. This depicts why structural processes are required to secure outcome quality and minimize the complications. The aftercare of HNS patients can be provided interdisciplinary and by different medical institutions, whereat, minimal reporting standards to document outcome and usage are recommended

CPAP therapy improves erectile function in patients with severe obstructive sleep apnea

Objectives: Erectile dysfunction (ED) is highly prevalent in obstructive sleep apnea (OSA), however, the effect of continuous positive airway pressure (CPAP) therapy on erectile function has not yet been thoroughly investigated in these patients. Methods: Ninety-four men with severe OSA (ie, with an apnea-hypopnea-index >= 30/h of sleep) were prospectively evaluated for the presence and severity of ED before and after 6-12 months of CPAP therapy. The abbreviated version of the International Index of Erectile Function, (the IIEF-5) was used to rate erectile function. Furthermore, all study participants responded to standard questionnaires of daytime sleepiness (Epworth Sleepiness Scale), quality of life (WHO Wellbeing 5 questionnaire) and depression (Major Depression Inventory). Results: ED as defined by an IIEF-5 score of <= 21 was present in 64 patients (68.1%). CPAP treatment significantly improved erectile function in those patients suffering from moderate and severe ED. Additionally, a trend for a correlation between the improvement of erectile function under CPAP and the hours of its use was observed. Finally, this effect was associated with larger improvements of quality of life in affected patients. Conclusions: ED is very frequent in men with severe OSA and can at least partly be reversed by long-term CPAP therapy in most seriously affected patients. The beneficial effect on erectile function may depend on CPAP compliance and is accompanied by improvements of quality of life. Randomized controlled trials are needed to confirm these findings. (c) 2018 Elsevier B.V. All rights reserved