The feasibility of using auto-titrating continuous positive airway pressure to treat obstructive sleep apnoea after acute tetraplegia

Abstract

Study design: A prospective cohort with acute tetraplegia. Objectives: Obstructive sleep apnoea (OSA) is common within weeks of tetraplegia. This study aimed at determining the feasibility of auto-titrating continuous positive airway pressure (CPAP) to treat OSA after acute tetraplegia. Setting: The Victorian Spinal Cord Service, Melbourne, Australia Methods: Participants underwent full, portable polysomnography. Those with an apnoea hypopnoea index of more than 10 events per hour were defined as having OSA and were offered treatment with CPAP. Treatment adherence was objectively monitored, and measures of quality of life, sleepiness and functional outcomes were determined at enrolment and 3 months later at study conclusion. Results: A total of 44 patients were admitted to our Spinal Cord Service over 9 months, and 19 participated. Fourteen of them had OSA and seven were adherent with therapy for 3 months. Compared with those who did not have OSA, and with those with OSA who were not adherent with CPAP, those who adhered to CPAP were older (mean (s.d.) age 54 years (13) versus non-adherent 28 years (15) and no OSA 29 years (10)) and heavier (body mass index (BMI) 32.5 (11.7), 24.1 (3.7) and 20.6 (3.1), respectively). CPAP-adherant patients and those without OSA showed a 50% or greater improvement in their state sleepiness over the 3 months. Patients with OSA who did not tolerate CPAP had no improvement in sleepiness. Conclusion: Auto-titrating CPAP is a feasible treatment for OSA in acute tetraplegia. Intensive clinical support was required initially, and a tolerance of therapy for at least 4 h for one of the first 3 days was predictive of good CPAP usage. Sponsorship: Transport Accident Commission.

Nasal Resistance Is Elevated in People with Tetraplegia and Is Reduced by Topical Sympathomimetic Administration

“…9 It is likely that the increased nasal resistance observed in this study contributes to both of these observations. In otherwise healthy individuals, nasal packing 13 can give rise to OSA and nasal decongestion with steroids and an α-adrenergic agent (dexamethasone and tramazoline) can reduce OSA severity in the able-bodied.…”

“…[2][3][4][5][6][7] Untreated OSA is a significant issue in tetraplegia as it is associated with significant neurocognitive deficits, sleepiness, and reduced quality of life. [2][3][4][5][6]8,9 Tetraplegia is likely to compromise the patency of the nose because sympathetic outflow to the upper airway is typically disrupted after cervical spinal cord injury. In an animal model, unopposed parasympathetic activation of the upper airway was observed to increase nasal airflow resistance.…”

“…13 Furthermore, in tetraplegia, this nasal obstruction has been specifically identified by patients with OSA as a predominant reason for non-adherence with the mainstay treatment for OSA, continuous positive airway pressure (CPAP). 9 Despite these observations, Upper airway patency and collapsibility are also influenced by the surface tension of the liquid lining the upper airway.…”

Sleep disordered breathing in spinal cord injury: A systematic review

“…24 Using the same criteria, the same authors reported in a cross sectional study of 78 patients a prevalence of 91% in acute complete tetraplegia and a prevalence of 56% in patients with acute incomplete tetraplegia. There was no relationship between the neurological level and AHI.…”

Continuous positive airway pressure requirements in patients with tetraplegia and obstructive sleep apnoea

“…Current data suggest CPAP adherence rates of 23-74% and those who are more sleepy are more likely to be adherent. 9,11 Reasons for non-adherence include nasal congestion, claustrophobia, inability to adjust the mask and anxiety. 9,11,12 There are no data investigating effective CPAP levels required to treat OSA in tetraplegia and whether this differs from able-bodied patients with OSA.…”