Sleep apnoea: treatment options and sleep/cardiovascular outcome

ESC CardioMed ◽  
2018 ◽  
pp. 1065-1069
Author(s):  
Holger Woehrle ◽  
Michael Arzt
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Upper Airway ◽  
Sleep Apnoea ◽  
Invasive Ventilation ◽  
Adaptive Servo Ventilation ◽  
Central Sleep Apnoea ◽  
Non Invasive ◽  
Non Invasive Ventilation ◽  
New Treatment

In addition to lifestyle interventions, treatments for obstructive sleep apnoea focus on maintaining upper airway patency. Continuous positive airway pressure (CPAP) is recommended as first-line therapy. Beneficial cardiovascular effects of CPAP include increased intrathoracic pressure, reduced left ventricular preload and afterload, and reduced transmural cardiac pressure gradients. CPAP also reduces nocturnal ischaemia and blood pressure, and decreases the risk of post-treatment atrial fibrillation recurrence. However, secondary prevention with CPAP did not significantly reduce the rate of major cardio- and cerebrovascular events in the SAVE study. Mandibular advancement devices, surgery, and upper airway stimulation are options for patients unwilling to use or tolerate CPAP. Central sleep apnoea and Cheyne–Stokes respiration are common in patients with heart disease, especially heart failure. Adaptive servo-ventilation is the most effective therapy for alleviating central sleep apnoea with Cheyne–Stokes respiration. However, it is now contraindicated in heart failure patients with an ejection fraction of 45% or lower and predominant central sleep apnoea because of an increased risk of cardiovascular death, based on SERVE-HF study results. However, adaptive servo-ventilation may still have a role in other settings, including heart failure with preserved ejection fraction. Phrenic nerve stimulation is a new treatment modality that has shown promising results in a feasibility study. Hypoventilation is another breathing disorder that needs effective management. Data in cardiovascular disease are lacking, but CPAP and non-invasive ventilation have been shown to be effective in patients with obesity hypoventilation syndrome. Furthermore, effective reduction of chronic hypercapnia during home non-invasive ventilation treatment in patients with chronic obstructive pulmonary disease has been shown to significantly improve survival.

scholarly journals Non-Invasive Ventilation in Patients with Heart Failure: A Systematic Review and Meta-Analysis

2017 ◽  
Author(s):  
Hugo Souza Bittencourt ◽  
Helena França Correia dos Reis ◽  
Melissa Santos Lima ◽  
Mansueto Gomes Neto
Keyword(s):  
Heart Failure ◽  
Systematic Review ◽  
Meta Analysis ◽  
Invasive Ventilation ◽  
Non Invasive ◽  
Non Invasive Ventilation ◽  
Patients With Heart Failure

scholarly journals Adaptive servo ventilation for central sleep apnoea in heart failure: SERVE-HF on-treatment analysis

2017 ◽  
Vol 50 (2) ◽  
pp. 1601692 ◽  
Author(s):  
Holger Woehrle ◽  
Martin R. Cowie ◽  
Christine Eulenburg ◽  
Anna Suling ◽  
Christiane Angermann ◽  
...  
Keyword(s):  
Heart Failure ◽  
Sleep Apnoea ◽  
Adaptive Servo Ventilation ◽  
Central Sleep Apnoea ◽  
Treatment Analysis

Abstract 15821: Safety and Efficacy of Non-invasive Ventilation During Exercise Training in Patients With Acute Heart Failure. A Randomized Prospective Controlled Study

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Mayron F Oliveira ◽  
Rita L Santos ◽  
Vanessa M Mendez ◽  
Priscila A Sperandio ◽  
Iracema I Umeda ◽  
...  
Keyword(s):  
Heart Failure ◽  
Exercise Training ◽  
Adverse Events ◽  
Hospital Stay ◽  
Length Of Hospital Stay ◽  
Invasive Ventilation ◽  
Serious Adverse Events ◽  
Safety And Efficacy ◽  
Non Invasive ◽  
Non Invasive Ventilation

Background: Exercise training (ET) is well established to improve functional capacity and quality of life in patients (pts) with chronic heart failure. However, the ET benefits in acute heart failure (AHF) are unknown. Purpose: We aimed to study the safety and efficacy of ET alone or combined with non-invasive ventilation (NIV) compared to standard medical treatment in hospitalized pts with AHF. Methods: Twenty-nine pts with AHF (68% ischemic), 56±7 years, left ventricle ejection fraction of 25±5%, NTproBNP of 2456±730, 6-minute walk test distance (6MWD = 225±39meters) were randomized into 3 groups: ET + NIV with sub therapeutic positive airway pressure (PAP) (ET,n=9), ET + NIV set to 14 of inspiratory and 8 cmH2O of expiratory PAP, respectively (EV,n=11) and standard treatment (CO,n=9). The ET and EV groups performed a daily session of unloaded exercise on cycle ergometer for 20 min or tolerance limit, for 8 consecutives days. In EV and ET, oxygen pulse saturation (SpO2), heart rate (HR), respiratory rate (RR), blood pressure (BP), blood lactate were measured at baseline (D1), during exercise, and at day 10 (D10). Serious adverse events (death or worsening heart failure) were also assessed on D10. Results: Length of hospital stay was shorter in EV group (17±10 days) compared to ET (23±8 days) and CO (39±15 days) (p<0,05). There were more serious adverse events in CO (66,6%) compared to both EV and ET (15%). Dobutamine use at D10 was less frequent in EV (18,2%) and ET (22,2%) groups than in CO (33,3%) (p<0.05). There was a marked improvement in Δ6MWD between D1 and D10 in EV (Δ127±72 meters), though increase in Δ6MWD was also seen in ET (Δ72±26 meters) and CO (Δ41±19meters), p<0,05. The EV group also showed higher endurance and lower peak HR at end-exercise than ET at D10 (128±10 vs. 92±8 min and 73±12 vs. 104±25 bpm, respectively; p<0,05). There was a similar reduction in NTproBNP levels but no differences were found in BP, SpO2, RR and blood lactate. Conclusion: Aerobic exercise in AHF was safe, reduced length of hospital stay and need for inotropics at D10. NIV + ET increased exercise endurance with lower cardiovascular stress.

scholarly journals 1260 High Tidal Volume Non-invasive Ventilation Required to Treat Obesity Hypoventilation

SLEEP ◽  
2020 ◽  
Vol 43 (Supplement_1) ◽  
pp. A479-A480
Author(s):  
Talayeh Rezayat ◽  
Abigail Beggs ◽  
Alon Y Avidan ◽  
Shahrokh Javaheri
Keyword(s):  
Tidal Volume ◽  
Upper Airway ◽  
Morbidly Obese ◽  
Obese Patients ◽  
Invasive Ventilation ◽  
Class Iii ◽  
Non Invasive ◽  
Non Invasive Ventilation ◽  
Patient Reported ◽  
Obesity Hypoventilation

Abstract Introduction Current guidelines recommend CPAP or non-invasive ventilation with tidal volume (VT) &lt;10ml/kg of ideal body weight (IBW) for the treatment of obesity hypoventilation. However, in select patients with significant obesity hypoventilation, this recommendation may not be sufficient to resolve nocturnal hypoventilation. Report of Case A 35 y/o male with hypertension and class III obesity (BMI 58 kg/m2) was referred for evaluation of acute respiratory failure with hypoxia and hypercapnia. ABG demonstrated daytime PCO2 of 71 mmHg. Patient reported sleep fragmentation, snoring, choke awakenings, poor concentration, depression and sleep attacks. PSG demonstrated severe OSA, with an AHI of 154 events/hour, persistent hypoxia and hypercapnia with a SpO2 nadir of 50% and ET-CO2 of 83 mmHg during REM sleep. Respiratory events persisted with CPAP and bilevel, up to a setting of 25/16. Average volume assured pressure support (AVAPS) S/T titration study was performed and resolved sleep apnea at settings of IPAP 24-30, EPAP 4-15, VT 790 (10 mL/kg IBW), 0.5 LPM O2, rate 16. The patient reported having had the best sleep of his life at the end of this study and has since been started on treatment. Conclusion Treatment of OHS should be individualized and may require use of tidal volumes above 10ml/kg for effective treatment. We suggest that in super morbidly obese patients, with extremely noncompliant respiratory system, larger than recommended tidal volume is necessary to ventilate the patient and improve gas exchange. The sustained higher pressures achieved by AVAPS to impose the augmented tidal volume more effectively ameliorate OSA, by keeping the upper airway open. Higher pressures achieved also could elevate FRC, not only increasing oxygen stores, but also contributing to maintenance of open upper airway through its tethering effect. Further physiological studies are needed in super morbidly obese patients comparing low and high tidal volumes.

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