Randomized Controlled Trial of Noninvasive Positive Pressure Ventilation (NPPV) Versus Servoventilation in Patients with CPAP-Induced Central Sleep Apnea (Complex Sleep Apnea)

Dellweg, Dominic; Kerl, Jens; Hoehn, Ekkehard; Wenzel, M; Koehler, Dieter

doi:10.5665/sleep.2878

Cited by 60 publications

(42 citation statements)

References 48 publications

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“…The study showed that both ASV and BPAP effectively resolve treatment-emergent CSA during the titration night, but only ASV maintained an effective suppression of CSA over time. Thus, ASV appears superior to BPAP for the long-term treatment of persistent CSA.The most intriguing observation from Dellweg et al 10 was the re-emergence of central events after 6 weeks with BPAP, despite the apparent absence of events on the titration night. Ideally, BPAP should effectively eliminate all central events if there is an adequate backup rate, tightly sealed mask, sufficient pressure support (inspiratory driving pressure), and stable respiratory mechanics.…”

mentioning

confidence: 80%

“…The most intriguing observation from Dellweg et al 10 was the re-emergence of central events after 6 weeks with BPAP, despite the apparent absence of events on the titration night. Ideally, BPAP should effectively eliminate all central events if there is an adequate backup rate, tightly sealed mask, sufficient pressure support (inspiratory driving pressure), and stable respiratory mechanics.…”

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confidence: 96%

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Adapting Our Approach to Treatment-Emergent Central Sleep Apnea

Edwards

Malhotra

Sands

2013

Sleep

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1121Editorial-Edwards et alWhile obstructive sleep apnea is effectively treated with continuous positive airway pressure (CPAP), roughly 10% of initial CPAP titrations result in emergence of central apneas or hypopneas, 1-3 a phenomenon referred to as treatment-emergent central sleep apnea (CSA). Although the majority of treatmentemergent CSA resolves with ongoing CPAP therapy, 4 some patients exhibit persistent CSA, creating a therapeutic challenge.Currently, the treatment options are to either continue using CPAP assessing whether central apneas naturally resolve (as occurs in > 90% of patients by 3 months 2,4-7 ) or try changing the mode of positive airway pressure (PAP) to either bilevel PAP (BPAP) with a backup rate or adaptive servoventilation (ASV). Although data are sparse, limited available evidence suggests that both BPAP and ASV improve CSA, although ASV may have a slight advantage over BPAP. 8,9 However, there has been a lack of longitudinal data examining the efficacy of either of these two modes of PAP. In this edition of SLEEP, Dellweg and colleagues 10 take the first step in filling the research void by conducting a randomized prospective comparative effectiveness study in patients whose CSA persisted after 6 weeks of CPAP. The study showed that both ASV and BPAP effectively resolve treatment-emergent CSA during the titration night, but only ASV maintained an effective suppression of CSA over time. Thus, ASV appears superior to BPAP for the long-term treatment of persistent CSA.The most intriguing observation from Dellweg et al. 10 was the re-emergence of central events after 6 weeks with BPAP, despite the apparent absence of events on the titration night. Ideally, BPAP should effectively eliminate all central events if there is an adequate backup rate, tightly sealed mask, sufficient pressure support (inspiratory driving pressure), and stable respiratory mechanics. Yet CSA elimination is not always seen in practice for reasons that are unclear.What might explain the occurrence of CSA on BPAP therapy? When BPAP is delivered noninvasively via a mask, the ultimate effect on tidal volume is determined by the respiratory system mechanics and the level of leak present. Importantly, by augmenting tidal volume, BPAP reduces CO 2 and thus the intrinsic ventilatory drive.11 If CO 2 is sufficiently lowered, apnea will be produced if BPAP fails to deliver tidal volume effec-

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confidence: 80%

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confidence: 96%

Adapting Our Approach to Treatment-Emergent Central Sleep Apnea

Edwards

Malhotra

Sands

2013

Sleep

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“…Bi-level positive airway pressure (BPAP) can be considered to treat patients with CompSAS; however, there has been some association with worsening central apneas [58]. A randomized controlled trial comparing BPAP and ASV showed that after 6 weeks, ASV was clearly superior with regards to residual AHI and elimination of central events [59]. Currently available evidence suggests that ASV is effective at treating treatment-emergent central sleep apnea.…”

Section: Asv For Treatment-emergent Central Sleep Apneamentioning

confidence: 99%

Advanced Positive Airway Pressure Modalities

Bierer¹,

Ryden

Aysola³

2015

Curr Sleep Medicine Rep

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Auto-adjusting positive airway pressure (PAP) devices are increasingly becoming the first line treatment for obstructive sleep apnea (OSA). More complex sleepdisordered breathing such as Cheyne-Stokes respirations and central sleep apnea related to heart failure as well as complex sleep-disordered breathing related to chronic hypoventilation syndromes may require the use of advanced positive airway pressure modalities such as automated servo ventilation (ASV) and volume targeted pressure limited ventilation. Identifying patients with complex sleep-disordered breathing that will benefit from treatment with advanced modalities remains an area of active investigation. A recent and surprising development found ASV to be associated with an increased risk of sudden cardiac death when used to treat central sleep apnea in patients with symptomatic systolic heart failure and an ejection fraction less than 45 %. The optimal treatment of central sleep apnea in heart failure and the role of ASV are currently in question. The following chapter is intended to provide the clinician with a description of newer PAP modalities; a review of evidence supported indications for use as well as provide a framework for managing patients with advanced positive airway pressure therapy.

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“…Although the scientific evidence for several of these situations is limited, data from cohort studies, follow-up series and some randomized controlled trials demonstrated the efficacy of ASV and its superiority to other treatment options, including oxygen, CPAP, bilevel PAP in spontaneous timed mode (BPAP-ST) [25,56,82,83]. Teschler et al applied different therapeutical options (O 2 , CPAP, BPAP-ST, ASV) randomly for one night each.…”

Section: Adaptive Servoventilationmentioning

confidence: 99%

Sleep-Disordered Breathing in Patients with Heart Failure

Randerath

Javaheri

2016

Curr Sleep Medicine Rep

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Breathing disturbances during sleep play a significant role in patients with cardiac diseases due to their high prevalence and impact on outcome. Obstructive sleep apnea (OSA) is a major risk factor of arterial hypertension and is associated with atrial fibrillation. A majority of heart failure (HF) patients suffer from OSA or central sleep apnoea (CSA), both associated with impaired prognosis. The application of continuous positive airway pressure has proven to improve symptoms and outcome in severe OSA. However, optimal therapy of CSA in heart failure is under discussion. Adaptive servoventilation (ASV) allows for counterbalancing the shift between hyperventilation and hypoventilation in periodic breathing. It has been shown to be superior to oxygen, continuous positive airway pressure therapy (CPAP) or other therapeutical options in HF patients with CSA. However, due to recent data, its use should be adapted closely to current indications and contraindications.

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Randomized Controlled Trial of Noninvasive Positive Pressure Ventilation (NPPV) Versus Servoventilation in Patients with CPAP-Induced Central Sleep Apnea (Complex Sleep Apnea)

Abstract: After 6 weeks, servoventilation treated respiratory events more effectively than NPPV in patients with complex sleep apnea syndrome.

Cited by 60 publications

References 48 publications

Adapting Our Approach to Treatment-Emergent Central Sleep Apnea

Adapting Our Approach to Treatment-Emergent Central Sleep Apnea

Advanced Positive Airway Pressure Modalities

Sleep-Disordered Breathing in Patients with Heart Failure

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