Factors Affecting Long-Term Compliance of CPAP Treatment—A Single Centre Experience

Continuous positive airway pressure (CPAP) has been the standard treatment of obstructive sleep apnoea/hypopnoea syndrome (OSA) for almost four decades. Though usually effective, this treatment suffers from poor long-term compliance. Therefore, the aim of our one centre retrospective study was to assess factors responsible for treatment failure and long-term compliance. Four hundred subsequent patients diagnosed with OSA and qualified for CPAP treatment were chosen from our database and compliance data were obtained from medical charts. Many differing factors kept patients from starting CPAP or led to termination of treatment. Overall, almost half of patients ended treatment during the mean time of observation of 3.5 years. Survival analysis revealed that 25% of patients failed at a median time of 38.2 months. From several demographic and clinical covariates in Cox’s hazard model, only the presence of a mild OSA, i.e., AHI (apnoea/hypopnoea index) below 15/h was a factor strongly associated with long term CPAP failure. The compliance results of our study are in line with numerous studies addressing this issue. Contrary to them, some demographic or clinical variables that we used in our survival model were not related to CPAP adherence.

Feasibility and Clinical Outcomes of a Step Up Noninvasive Respiratory Support Strategy in Patients with Severe COVID-19 Pneumonia

The best noninvasive respiratory strategy in patients with Coronavirus Disease 2019 (COVID-19) pneumonia is still discussed. We aimed at assessing the rate of endotracheal intubation (ETI) in patients treated with continuous positive airway pressure (CPAP) and noninvasive ventilation (NIV) if CPAP failed. Secondary outcomes were in-hospital mortality and in-hospital length of stay (LOS). A retrospective, observational, multicenter study was conducted in intermediate-high dependency respiratory units of two Italian university hospitals. Consecutive patients with COVID-19 treated with CPAP were enrolled. Thoraco-abdominal asynchrony or hemodynamic instability led to ETI. Patients showing SpO2 ≤ 94%, respiratory rate ≥ 30 bpm or accessory muscle activation on CPAP received NIV. Respiratory distress and desaturation despite NIV eventually led to ETI. 156 patients were included. The overall rate of ETI was 30%, mortality 18% and median LOS 24 (17–32) days. Among patients that failed CPAP (n = 63), 28% were intubated, while the remaining 72% received NIV, of which 65% were intubated. Patients intubated after CPAP showed lower baseline PaO2/FiO2, lower lymphocyte counts and higher D-dimer values compared with patients intubated after CPAP + NIV. Mortality was 22% with CPAP + ETI, and 20% with CPAP + NIV + ETI. In the case of CPAP failure, a NIV trial appears feasible, does not deteriorate respiratory status and may reduce the need for ETI in COVID-19 patients.

475 Automatic detection of self-similarity and prediction of CPAP failure

Introduction Sleep disordered breathing is a significant risk factor for cardiometabolic and neurodegenerative diseases. Tolerance and efficacy of continuous positive airway pressure (CPAP), the primary form of therapy for sleep apnea, is often poor. High loop gain (HLG) is a driving mechanism of central sleep apnea or periodic breathing. The current study aimed to develop a computational approach to detect HLG based on self-similarity in respiratory oscillations during sleep solely using breathing patterns, measured via Respiratory Inductance Plethysmography (RIP). To quantify the potential utility of the developed similarity metric, the presented algorithm was used to predict acute CPAP failure. Methods We developed an algorithm for detecting apneas as periods with reduced breathing effort, manifested in the RIP signal as low signal amplitude. Our algorithm calculates self-similarity in breathing patterns between consecutive periods of apnea or hypopnea. Working under the assumption that high loop gain induces self-similar respiratory oscillations and increases the risk of failure during CPAP, the full night similarity, computed during diagnostic non-CPAP polysomnography (PSG), was used to predict failure of CPAP, which we defined as titration central apnea index (CAI)>10. Central apnea labels are obtained both from manual scoring by sleep technologists, and from an automated algorithm developed for this study. The Massachusetts General Hospital (MGH) sleep database was used, including 2466 PSG pairs of diagnostic and CPAP titration PSG recordings. Results Diagnostic CAI based on technologist labels predicted failure of CPAP with an AUC of 0.82 ±0.03. Based on automatically generated labels, the combination of full night similarity and automatically generated CAI resulted in an AUC of 0.85 ±0.02. A subanalysis was performed on a population with technologist labeled diagnostic CAI>5. Full night similarity predicted failure with an AUC of 0.57 ±0.07 for manual and 0.65 ±0.06 for automated labels. Conclusion This study showed that central apnea labels can be derived in an automated way. The proposed self-similarity feature, as a surrogate estimate of expressed respiratory high loop gain and computed from easily accessible effort signals, can detect periodic breathing regardless of admixed obstructive features such as flow-limitation, and can aid prediction of CPAP failure or success. Support (if any):

Helmet CPAP to treat hypoxic pneumonia outside the ICU: an observational study during the COVID-19 outbreak

Background Respiratory failure due to COVID-19 pneumonia is associated with high mortality and may overwhelm health care systems, due to the surge of patients requiring advanced respiratory support. Shortage of intensive care unit (ICU) beds required many patients to be treated outside the ICU despite severe gas exchange impairment. Helmet is an effective interface to provide continuous positive airway pressure (CPAP) noninvasively. We report data about the usefulness of helmet CPAP during pandemic, either as treatment, a bridge to intubation or a rescue therapy for patients with care limitations (DNI). Methods In this observational study we collected data regarding patients failing standard oxygen therapy (i.e., non-rebreathing mask) due to COVID-19 pneumonia treated with a free flow helmet CPAP system. Patients’ data were recorded before, at initiation of CPAP treatment and once a day, thereafter. CPAP failure was defined as a composite outcome of intubation or death. Results A total of 306 patients were included; 42% were deemed as DNI. Helmet CPAP treatment was successful in 69% of the full treatment and 28% of the DNI patients (P < 0.001). With helmet CPAP, PaO2/FiO2 ratio doubled from about 100 to 200 mmHg (P < 0.001); respiratory rate decreased from 28 [22–32] to 24 [20–29] breaths per minute, P < 0.001). C-reactive protein, time to oxygen mask failure, age, PaO2/FiO2 during CPAP, number of comorbidities were independently associated with CPAP failure. Helmet CPAP was maintained for 6 [3–9] days, almost continuously during the first two days. None of the full treatment patients died before intubation in the wards. Conclusions Helmet CPAP treatment is feasible for several days outside the ICU, despite persistent impairment in gas exchange. It was used, without escalating to intubation, in the majority of full treatment patients after standard oxygen therapy failed. DNI patients could benefit from helmet CPAP as rescue therapy to improve survival. Trial Registration: NCT04424992

Helmet CPAP to treat hypoxic pneumonia outside the ICU: an observational study during the COVID-19 outbreak

Background: Respiratory failure due to COVID-19 pneumonia is associated with high mortality and may overwhelm health care systems, due to the surge patients requiring advanced respiratory support. Shortage of intensive care unit (ICU) beds required many patients to be treated outside the ICU despite severe gas exchange impairment. Helmet is as effective interface to provide Continuous Positive Airway Pressure (CPAP) non-invasively. We report data about the usefulness of helmet CPAP during pandemic, either as an effective treatment, a bridge to intubation or a rescue therapy for patients with care limitations (DNI).Methods: In this observational study we collected data regarding patients failing standard oxygen therapy (i.e. non-rebreathing mask) due to COVID-19 pneumonia treated with a free flow helmet CPAP system. Patients’ data were recorded before, at initiation of CPAP treatment and once a day, thereafter. CPAP failure was defined as a composite outcome of intubation or death.Results: A total of 306 patients were included; 42% were deemed as DNI. Helmet CPAP treatment was successful in 69% of the full-treatment and 28% of the DNI patients (P<0.001). With helmet CPAP, PaO2/FiO2 ratio doubled from about 100 to 200 mmHg (P<0.001); respiratory rate decreased from 28 [22-32] to 24 [20-29] breaths per minute, P<0.001). C-Reactive Protein, time to oxygen mask failure, age, PaO2/FiO2 during CPAP, number of comorbidities were independently associated with CPAP failure. Helmet CPAP was maintained for 6 [3-9] days, almost continuously during the first two days. None of the full treatment patients died before intubation in the wards.Conclusions: Helmet CPAP treatment is feasible for several days outside the ICU, despite persistent impairment in gas exchange. It was used, without escalating to intubation, in the majority of full treatment patients after standard oxygen therapy failed. DNI patients could benefit from helmet CPAP as rescue therapy to improve survival.Trial Registration: NCT04424992

Predictor Factors of Continuous Positive Airway Pressure Failure in Preterm Infants with Respiratory Distress

Respiratory distress contributes significantly to mortality, and morbidity in preterm infants. The incidence of nasal continuous positive airway pressure (CPAP) failure is remarkably high. There are limited data available regarding nasal CPAP failure in Indonesia, and this study is expected to be a reference in taking preventive measures to reduce mortality and morbidity in preterm infants. To determine predictive factors of nasal CPAP failure in preterm infants with respiratory distress. A retrospective cohort study was conducted in preterm infants with respiratory distress at the Neonatology ward of Dr. Sardjito Hospital during January 2017-July 2019. Chi-square or Fisher’s exact tests, followed by multivariate logistic regression analysis with backward method, was used to identify factors contributing to nasal CPAP failure. A total of 150 infants were included in this study. Fifty-three (37.8%) infants had nasal CPAP failure. Bivariate analysis showed birth weight <1000 g, singleton, APGAR score 4-7, premature rupture of membrane (PROM), Downes score, and initiation of fractional concentration of inspired (FiO2) requirement were all risk factors of nasal CPAP failure. However, only birth weight <1000 g ( P = .022; OR 2.69; CI 95% 1.34-5.44), initial Downes score ( P = .035; OR 2.68; CI 95% 3.10-24.11), and initiation of FiO2 requirement ≥30% ( P = .0001; OR 3.03; CI 95% 2.04-4.50) were significant predictors for nasal CPAP failure by multivariate analysis. Birth weight <1000 g, singleton, initial Downes score, and initiation of FiO2 requirement >30% were significant predictors of nasal CPAP failure in preterm infants with respiratory distress.

Neonatal Preterm Respiratory Care in Ukraine: An Observational Study of Outcomes in Relation to Timing and Methods of Surfactant Treatment

Objective Timely and effective noninvasive respiratory support and surfactant administration are the key determinants of clinical outcomes in very preterm infants. The objective of this study was to evaluate the impact of the changes in clinical practice of surfactant administration on clinical outcomes and the incidence of continuous positive airway pressure (CPAP) failure defined as the need for mechanical ventilation (MV) during the first 5 days of life in preterm infants <32 weeks. Study Design One hundred sixty-five outborn very preterm infants with respiratory distress syndrome (RDS), initially managed on CPAP, were enrolled in a retrospective cohort study. Fifty-two infants treated with surfactant using less invasive or INSURE technique were included in the surfactant group. One hundred thirteen control infants received surfactant only in case of CPAP failure. Results The study groups were similar in gestational age, rates of main obstetric complications, and antenatal steroid prophylaxis. The rate of cesarean delivery was significantly higher but birth weight and need for resuscitation were lower in infants from the surfactant group. Fifty-five infants with CPAP failure (49%) received surfactant after initiation of MV in the control group in comparison with 52 (100%) in the surfactant group (p < 0.001). The incidence of CPAP failure was significantly higher in the control group (49 vs. 27%; p < 0.01) and it occurred earlier (median [interquartile range age: 4 [2–5] vs. 47 [36–99] hours, respectively; p < 0.001). Early surfactant administration significantly and independently affected the probability of CPAP failure (adjusted odds ratio: 0.29, 95% confidence interval: 0.13–0.67; p < 0.01). There were no differences in morbidities between the groups, but CPAP failure was significantly associated with higher morbidity and mortality. Conclusion Adherence to the European RDS guidelines with early rescue, less invasive surfactant administration in very preterm infants decreased the probability of CPAP failure which was significantly associated with higher morbidity and mortality. Key Points