Effects of Dynamic Bilevel Positive Airway Pressure Support on Central Sleep Apnea in Men With Heart Failure*

Arzt, Michael; Wensel, Roland; Montalvan, Sylvia; Schichtl, Thomas; Schroll, Stephan; Budweiser, Stephan; Blumberg, Friedrich C.; Riegger, G. A. J.; Pfeifer, Michael

doi:10.1378/chest.07-1620

Cited by 121 publications

(63 citation statements)

References 19 publications

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“…[23][24][25]29,30 The outcomes of therapy have also varied considerably, with limited evidence to establish the effectiveness of any therapy for CSA. [26][27][28][29]31,32 The majority of published literature has focused on the treatment of CSA secondary to congestive heart failure (CHF), [2][3][4][5][6][7][8][9][10][11][15][16][17][18][19][20][21][22][26][27][28][29] with very little data on patients with "primary" CSA 23,24 or CSA secondary to causes other than CHF. 33 In addition, there is very little data on the treatment of CSA related to opioid use and CSA that is concomitant with OSA.…”

Section: S C I E N T I F I C I N V E S T I G a T I O N Smentioning

confidence: 99%

Treatment of Central Sleep Apnea in US Veterans

Chowdhuri

Ghabsha

Sinha

et al. 2012

Journal of Clinical Sleep Medicine

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Background: There are no standard therapies for the management of central sleep apnea (CSA). Either positive pressure therapy (PAP) or supplemental oxygen (O 2 ) may stabilize respiration in CSA by reducing ventilatory chemoresponsiveness. Additionally, increasing opioid use and the presence of comorbid conditions in US veterans necessitates investigations into alternative titration protocols to treat CSA. The goal was to report on the effectiveness of titration with PAP, used alone or in conjunction with O 2 , for the management of CSA associated with varying comorbidities and opioid use. Methods: This was a retrospective chart review over 3 years, performed at a VA sleep disorders center. The effects of CPAP, CPAP+O 2 , and BPAP+O 2 , used in a step-wise titration protocol, on consecutive patients diagnosed with CSA were studied. Results: CSA was diagnosed in 162 patients. The protocol was effective in eliminating CSA (CAI ≤ 5/h) in 84% of patients. CPAP was effective in 48%, while CPAP+O 2 combination was effective in an additional 25%, and BPAP+O 2 in 11%. The remaining 16% were non-responders. Forty-seven patients (29%) were on prescribed opioid therapy for chronic pain, in whom CPAP, CPAP+O 2 , or BPAP+O 2 eliminated CSA in 54%, 28%, and 10% cases,, respectively. CPAP, CPAP+O 2 , and BPAP+O 2 each produced signifi cant declines in the AHI, CAI, and arousal index, and an increase in the SpO 2 .Conclusion: The data demonstrate that using a titration protocol with CPAP and then PAP with O 2 effectively eliminates CSA in individuals with underlying comorbid conditions and prescription opioid use. Comparative studies with other therapeutic modalities are required. S C I E N T I F I C I N V E S T I G A T I O N ST he treatment of central sleep apnea (CSA) continues to lack a universally recognized standard of care.1 Variable etiologies of CSA and the presence of concomitant disorders infl uence the choice of therapy. Thus, therapeutic options have varied markedly from positive airway pressure (PAP) devices, including continuous positive airway pressure (CPAP), 2-6 bilevel positive airway pressure therapy (BPAP), 7-9 and adaptive servoventilation, [10][11][12][13]20 to supplemental O 2 , 14-17 carbon dioxide, 21,22 and/or pharmacologic agents. [23][24][25]29,30 The outcomes of therapy have also varied considerably, with limited evidence to establish the effectiveness of any therapy for CSA. [26][27][28][29]31,32 The majority of published literature has focused on the treatment of CSA secondary to congestive heart failure (CHF), [2][3][4][5][6][7][8][9][10][11][15][16][17][18][19][20][21][22][26][27][28][29] with very little data on patients with "primary" CSA 23,24 or CSA secondary to causes other than CHF. 33 In addition, there is very little data on the treatment of CSA related to opioid use and CSA that is concomitant with OSA. 13,35 The latter entities are of increasing importance in the US veteran population due to the increased use of prescription opioid drugs for chronic pain control and the risk for opioi...

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Section: S C I E N T I F I C I N V E S T I G a T I O N Smentioning

confidence: 99%

Treatment of Central Sleep Apnea in US Veterans

Chowdhuri

Ghabsha

Sinha

et al. 2012

Journal of Clinical Sleep Medicine

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“…24 Treatment with respiratory assist devices (RADs) such as adaptive servo-ventilation, in patients with central apnea has been shown to lead to a dramatic improvement in achieving AHIs in the optimal treatment range (AHI < 5.0) during PAP titration. 25,26 Clinically, utilization of these systems is limited by cost, adaptability to existing titration protocols, and a limitation in the number and quality of applicable research studies. This study indicates that the O 2 > CPAP/Bilevel PAP protocol used in this study is effective in treating altitude-associated central apnea in OSA patients as an alternative to RAD systems.…”

Section: Resultsmentioning

confidence: 99%

The Effects of Altitude Associated Central Apnea on the Diagnosis and Treatment of Obstructive Sleep Apnea: Comparative Data from Three Different Altitude Locations in the Mountain West

Pagel

Kwiatkowski²,

Parnes

2011

Journal of Clinical Sleep Medicine

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Study Objectives: This study documents both the incidence and effects of central apnea on diagnosis and treatment of OSA at different altitudes in the Mountain West and substantiates the clinical impression that individuals living at altitude with moderate to severe OSA are signifi cantly more diffi cult to treat with PAP. Methods: Split-night polysomnography was compared between sites for patients with a diagnostic AHI > 15 living at 1421 meters (Site 1; N = 150), at 1808 m (Site 2; N = 150) and at 2165 m (Site 3; N = 142). The quality of PAP titration obtained was rated, based on AASM clinical guidelines, from 1 = optimal to 4 = unacceptable. Patients developing central apneas during PAP therapy (CAI > 5.0) were titrated with an alternative O 2 > CPAP/Bilevel PAP protocol. Results: The mean number of central apneas in the diagnostic portion of studies was signifi cantly higher (p < 0.01) at Sites 2 (19.26) and 3 (12.36) than at Site 1 (3.11). Mean numbers of central apneas/h developing on treatment with PAP varied from 4.8/h at Site 1, to 9.79/h at Site 2, to 19.25/h at Site 3 (p < 0.001). At Site 1, 10.6% had a central apnea index (CAI) > 5.0, while 22% met this criterion at Site 2 and 38.7% at Site 3 (Site 3 vs Site 1, p = 0.01; Site 2 vs Site 1, p = 0.02). Rated titration quality varied signifi cantly between sites. At Site 1, mean titration quality was 1.437 (SD 0.821); for Site 2, 1.569 (SD 0.96), and for Site 3, 1.772 (SD 1.025). Titration quality at Site 3 was signifi cantly worse than at Site 1 (t = 3.22, p < 0.01) and at Site 2 (t = 2.55, p < 0.02). Repeat titration requirement differed signifi cantly (p = 0.025). Analysis of covariance comparing titration across 3 altitude levels, controlling for age, was signifi cant for the effect of altitude (p = 0.017). Utilizing the alternative O 2 > C-PAP/Bi-PAP protocol in patients with CAI > 5.0 developing on PAP treatment, an overall optimal or good titration (AASM criteria) was attained in 75/79 (95%) of titrated patients. Conclusions: This study demonstrates that central apnea becomes signifi cantly more common at increasing altitude in both diagnostic and treatment portions of split-night polysomnography in patients with signifi cant OSA. An apparent exponential increase in the percentage of OSA patients with a CAI > 5.0 occurs with increasing altitude. Altitude associated central apnea has a signifi cant negative effect on the quality of OSA treatment obtained during PAP titration for patients living at the altitudes addressed in this study.

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“…It should also be added that other forms of noninvasive ventilation such as bilevel positive airway pressure (BIPAP) and non-invasive positive airway pressure (NPAP) have also been offered in HF patients with CSA/CSR. Some RCTs suggested the superiority of BIPAP to CPAP in improvement of LVEF in patients with systolic dysfunction and CSA and in reducing the CSA-CSR index (56). However, as these patients already hyperventilate and are high risk of hypocapnia, which in turn also may trigger central apneas, the use of BIPAP was not supported widely.…”

Section: Impact Of Cpap On Pulmonary Arterial Hypertension (Ph)mentioning

confidence: 99%