Safety and Tolerability of Early Noninvasive Ventilatory Correction Using Bilevel Positive Airway Pressure in Acute Ischemic Stroke

Tsivgoulis, Georgios; Zhang, Yi; Alexandrov, Anne W.; Harrigan, Mark R.; Sisson, April; Zhao, Limin; Brethour, Mary K.; Cava, Luis; Balucani, Clotilde; Barlinn, Kristian; Patterson, Damon E.; Giannopoulos, Sotirios; DeWolfe, Jennifer; Alexandrov, Andrei V.

doi:10.1161/strokeaha.110.600221

Cited by 35 publications

(21 citation statements)

References 22 publications

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“…Moreover, continuous positive airway pressure improves short-term functional outcome in stroke survivors with SA undergoing rehabilitation [24]. Apart from that, fewer publications showed feasibility and safety of early non-invasive ventilatory correction in the acute phase of stroke addressing the important association of SA and early neurological deterioration [10, 25–27]. However, timely detection of vascular risk factors remains a crucial key issue when goals for secondary prevention of stroke are defined [12].…”

Section: Discussionmentioning

confidence: 99%

Early sleep apnea screening on a stroke unit is feasible in patients with acute cerebral ischemia

et al. 2012

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Early screening for sleep apnea (SA) is rarely considered in patients with acute cerebral ischemia. We aimed to evaluate the feasibility of early SA screening on a stroke unit, its impact on post-discharge SA care and the relation of SA to clinical features. Patients with acute ischemic stroke (AIS) and transient ischemic attack (TIA) prospectively underwent overnight cardiorespiratory polygraphy within 3 ± 2 days of symptom-onset. Feasibility was defined as analyzable polygraphy in 90 % of studied patients. We enrolled 61 patients (84 % AIS, 16 % TIA): mean age 66 ± 8 years, 44 % men, median NIHSS 1 (0–15), median ESS 5 (0–13). Analyzability was given in 56/61 (91.8 %; one-sided 95 % CI, lower-bound 86.0 %) patients indicating excellent feasibility of early SA screening with no significant differences in stroke severity (100 % in TIA, 91 % minor stroke, 83 % major stroke, p = 0.474). Ninety-one percent (51/56) had an apnea–hypopnea index ≥5/h (median: 20/h [0–79]); 32 % (18/ 56) mild, 30 % (17/56) moderate, and 29 % (16/56) severe SA. When comparing sleep-related ischemic stroke (SIS) and non-SIS patients, no differences were found regarding the presence (95 vs. 89 %, p = 0.49) or severity (e.g., severe SA: 32 vs. 27 %, p = 0.69) of SA. After 12 months, 27/38 (71 %) patients given specific recommendations completed in-laboratory sleep work-up and 7/27 (25 %) were prescribed for non-invasive ventilatory correction. In conclusion, early SA screening is feasible in patients with acute cerebral ischemia and may have a positive impact on post-discharge SA care. Given the high frequency and atypical presentation of SA, early screening for SA should be considered in all acute cerebral ischemia patients.

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Section: Discussionmentioning

confidence: 99%

Early sleep apnea screening on a stroke unit is feasible in patients with acute cerebral ischemia

et al. 2012

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“…We found that both the degree of sleep apnea (as indicated by the AHI) and the extent of leukoaraiosis had an unfavorable impact on functional outcome emphasizing the importance of broad vascular risk factor screening as part of routine stroke work-up in this patient population. The challenge with sleep apnea identification in the acute setting of ischemic stroke has been a lack of clinical patient selection criteria for performing specific sleep studies [17,[35][36][37]. Chronic microvascular brain tissue changes could indirectly unmask stroke patients with a long-lasting history of sleep apnea requiring focused attention and define an at-risk population that could be tested in an acute or secondary prevention clinical trial for treatment of sleep apnea [38].…”

Section: Discussionmentioning

confidence: 99%

Association of sleep apnea with clinically silent microvascular brain tissue changes in acute cerebral ischemia

et al. 2013

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The aim of this study was to determine the importance of sleep apnea in relation to clinically silent microvascular brain tissue changes in patients with acute cerebral ischemia. Patients with acute cerebral ischemia prospectively underwent nocturnal respiratory polygraphy within 5 days from symptom-onset. Sleep apnea was defined as apnea-hypopnea-index (AHI) ≥5/h. Experienced readers blinded to clinical and sleep-related data reviewed brain computed tomography and magnetic resonance imaging scans for leukoaraiosis and chronic lacunar infarctions. Ischemic lesions were considered clinically silent when patients did not recall associated stroke-like symptoms. Functional outcome was assessed with modified Rankin Scale at discharge, 6 and 12 months. Fifty-one of 56 (91 %) patients had sleep apnea of any degree. Patients with moderate-tosevere leukoaraiosis (Wahlund score ≥5) were found to have higher mean AHI than those with none or mild leukoaraiosis (34.4 vs. 12.8/h, p < 0.001). Moderate-to-severe sleep apnea (AHI >15/h) was found to be an independent predictor of moderate-to-severe leukoaraiosis (adjusted OR 6.03, 95 % CI 1.76-20.6, p = 0.0042) and of moderate-to-severe leukoaraiosis associated with clinically silent chronic lacunar infarctions (adjusted OR 10.5, 95 % CI 2.19-50.6, p = 0.003). The higher the Wahlund score and the AHI, the more likely unfavorable functional outcome resulted over time (p = 0.0373). In acute cerebral ischemia, sleep apnea is associated with clinically silent microvascular brain tissue changes and may negatively influence functional outcome. Routine sleep apnea screening and further investigation of possible long-term effects of non-invasive ventilatory treatment of sleep apnea appear warranted in this at-risk population.

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“…However, this alternative may not be safe in patients with compromised airway patency and has not been tested in stroke patients with severe respiratory failure. 140,141 For those electing a pure palliative approach, efforts to control dyspnea, anxiety, and pain should be optimized while committing to ongoing intense care aligned with the patient's goals (which may be an intensive comfort-oriented approach). Patients with a DNI order in place should receive all other appropriate medical and surgical interventions unless otherwise explicitly indicated.…”

Section: Strokementioning

confidence: 99%

Palliative and End-of-Life Care in Stroke

Holloway¹,

Arnold²,

Creutzfeldt³

et al. 2014

Stroke

235

120

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Background and Purpose-The purpose of this statement is to delineate basic expectations regarding primary palliative care competencies and skills to be considered, learned, and practiced by providers and healthcare services across hospitals and community settings when caring for patients and families with stroke. Methods-Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and the American Heart Association's Manuscript Oversight Committee. Members were chosen to reflect the diversity and expertise of professional roles in delivering optimal palliative care. Writing group members were assigned topics relevant to their areas of expertise, reviewed the appropriate literature, and drafted manuscript content and recommendations in accordance with the American Heart Association's framework for defining classes and level of evidence and recommendations. Results-The palliative care needs of patients with serious or life-threatening stroke and their families are enormous: complex decision making, aligning treatment with goals, and symptom control. Primary palliative care should be available to all patients with serious or life-threatening stroke and their families throughout the entire course of illness. To optimally deliver primary palliative care, stroke systems of care and provider teams should (1) promote and practice patient-and family-centered care; (2) effectively estimate prognosis; (3) develop appropriate goals of care; (4) be familiar with the evidence for common stroke decisions with end-of-life implications; (5) assess and effectively manage emerging stroke symptoms; (6) possess experience with palliative treatments at the end of life; (7) assist with care coordination, including referral to a palliative care specialist or hospice if necessary; (8) provide the patient and family the opportunity for personal growth and make bereavement resources available if death is anticipated; and (9) actively participate in continuous quality improvement and research. Conclusions-Addressing the palliative care needs of patients and families throughout the course of illness can complement

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Safety and Tolerability of Early Noninvasive Ventilatory Correction Using Bilevel Positive Airway Pressure in Acute Ischemic Stroke

Cited by 35 publications

References 22 publications

Early sleep apnea screening on a stroke unit is feasible in patients with acute cerebral ischemia

Early sleep apnea screening on a stroke unit is feasible in patients with acute cerebral ischemia

Association of sleep apnea with clinically silent microvascular brain tissue changes in acute cerebral ischemia

Palliative and End-of-Life Care in Stroke

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