Joaquim Moita

Clinical impact of adaptive servoventilation compared to other ventilatory modes in patients with treatment-emergent sleep apnea, central sleep apnea and Cheyne---Stokes respiration

INTRODUCTION Adaptive servoventilation is a recent ventilatory mode initially designed to treat Cheyne-Stokes respiration (CSR). Recently, the efficacy of ASV has been discussed for the treatment of central sleep apnea (CSA) and treatment-emergent central sleep apnea (treatment-emergent CSA) where other forms of traditional positive airway pressure (PAP) may be insufficient. OBJECTIVES To compare the clinical impact of ASV with other forms of PAP in treating patients with treatment-emergent CSA, CSA and CSR. METHODS Medical data of all the patients who underwent polysomnography (PSG) with ASV titration were evaluated. The patients were divided into two groups according to the mode of ventilation reimbursed: ASV and PAP (AutoCPAP/CPAP/BIPAP). All patients had a minimal follow-up of 6 months. Both groups were compared in terms of symptoms, apnea hypopnea index, compliance, cardiac function and cardiovascular events. RESULTS ASV titration was performed in 33 patients (30M/3F) with a mean age of 69±8 years. The majority (58%) present a treatment-emergent SA and 42% a CSA and or CSR. The median initial diagnostic AHI was 46±22events/h. After the initial diagnosis, 28 patients were treated with PAP and 5 with servoventilation. All of the patients treated with PAP were posteriorly submitted to PSG and ASV titration because of suboptimal response to PAP. Despite a clear indication for ASV, due to differences in reimbursement, 15 patients continued treatment with PAP (12 with AutoCPAP, 1 with BIPAP and 2 with CPAP) and 16 changed to ASV. Two patients were lost in follow-up. In both groups, most of patients present a treatment-emergent SA (53% in ASV group vs. 67% in PAP group) or a CSA/CSR (29.4% in ASV group vs. 20% in PAP). After ASV titration, the mean follow-up was 25±14 months. Both groups (ASV vs. PAP) were similar in terms of compliance (77±23% vs.88±14%) and in terms of Epworth sleepiness scale score (6±5 vs. 7±5). There was a statistical difference in terms of residual AHI: mean AHI was 4±3 in ASV group and 9±3 in PAP group (P=0.005). We found no differences in terms of left ventricular fractional shortening (ASV 33±10% vs. PAP 32±10%). Although no difference was observed between the 2 groups in terms of non-fatal cardiovascular events (3 events in each group), 2 fatal cardiovascular events occurred in the PAP group (sudden death). CONCLUSIONS These data confirm that ASV is an efficient treatment in patients with treatment-emergent CSA, CSA/CSR significantly decreasing residual AHI. In both groups, compliance rate was high and sleepiness improved. It is relevant that the 2 patients who died of sudden death were treated with PAP.

Prospective study to evaluate AutoCPAP accuracy in treating respiratory effort: AutoCPAP vs CPAP

Introduction In our daily practice we have noticed that, particularly when there is a predominance of respiratory effort, AutoCPAP cannot always control patients’ symptoms and they appear to tolerate better a fixed CPAP pressure. However, in the literature, there is no evidence sustaining this observation. So we designed a prospective study to evaluate the best treatment modality for these patients. Methods We included patients with a Respiratory Disturbance Index (RDI) > 15events/h and Respiratory Rffort-Related Arousals (RERAs) > 50% of all the events. They started Auto CPAP S9 and then switched to a fixed CPAP pressure. After 3 months with each modality, all patients performed a polysomnography to evaluate its accuracy in treating respiratory sleep events. Results Seven patients completed the protocol. We observed a significant reduction in RDI (3,9±2,8; p=0,001) and in the mean number of RERAs (23,3 ±13,4; p=0,000) with AutoCPAP, but three patients maintained residual apnea (RDI>5 events/h). With fixed CPAP there was an additional reduction in the number of RERAs (0.6±1.5; p=0,004) and all had a RDI Discussion Both modalities were effective in treating respiratory sleep apnea, but CPAP was better at correcting respiratory effort and in controlling patients’ symptoms.

Home Mechanical Ventilation and Quality of Life in Neuromuscular Patients During Noninvasive Mechanical Ventilation: New Trends and Key Practical Topics

Many chronic neuromuscular disorders lead to progressive respiratory muscle dysfunction, which in turn can lead to respiratory failure and death. The impact and benefits of home noninvasive mechanical ventilation are currently well known. Noninvasive ventilation improves quality of life and survival in patients with neuromuscular diseases and chronic respiratory failure. In advanced disorders, symptoms can be palliated even if mortality is not reduced.

APNEIA CENTRAL DO SONO EMERGENTE DO TRATAMENTO

Oitenta e cinco pacientes com DP atendidos num hospital universitário, que concordaram em participar da pesquisa e assinaram o termo de consentimento livre e esclarecido, foram entrevistados. A entrevista consistia em responder à Escala de Sono na doença de Parkinson (ESDP) e à Escala Unificada de Avaliação da Doença de Parkinson (UPDRS). A primeira consiste numa escala analógica composta de 15 itens, cuja pontuação varia de zero a dez em cada um deles. Quanto menor o escore, mais graves e numerosas são as alterações do sono. Em contrapartida, um escore alto está relacionado com alterações leves ou inexistentes. A segunda é formada por sete partes e avalia a gravidade da doença, sendo que uma pontuação elevada está associada com doença mais avançada. O escore máximo desta é de 147. Os dados levantados foram analisados no programa SPSS versão 17.0 e o valor de po0,05 foi escolhido como estatisticamente significativo.

Ethical limits for noninvasive ventilation prescription.

Non-profit academic project, developed under the open access initiative