M Treml

Long-term Auto-Servoventilation or Constant Positive Pressure in Heart Failure and Coexisting Central With Obstructive Sleep Apnea

BACKGROUND The coexistence of obstructive sleep apnea (OSA) and central sleep apnea (CSA) and Cheyne-Stokes respiration (CSR) is common in patients with heart failure (HF). While CPAP improves CSA/CSR by about 50%, maximal suppression is crucial in improving clinical outcomes. Auto-servoventilation (ASV) effectively suppresses CSA/CSR in HF, but few trials have been performed in patients with coexisting OSA and CSA/CSR. Our objective was to evaluate a randomized, controlled trial to compare the efficacy of ASV and CPAP in reducing breathing disturbances and improving cardiac parameters in patients with HF and coexisting sleep-disordered breathing. METHODS Both modes were delivered using the BiPAP autoSV (Philips Respironics) over a 12-month period. Seventy patients (63 men, 66.3 ± 9.1 y, BMI 31.3 ± 6.0 kg/m(2)) had coexisting OSA and CSA/CSR, arterial hypertension, coronary heart disease, or cardiomyopathy and clinical signs of heart failure New York Heart Association classes II-III. Polysomnography, brain natriuretic peptide (BNP), spiroergometry, and echocardiography were performed at baseline and after 3 and 12 months of treatment. RESULTS Both modes of therapy significantly improved respiratory disturbances, oxygen desaturations, and arousals over the study period. ASV reduced the central apnea hypopnea index (baseline CPAP, 21.8 ± 11.7; ASV, 23.1 ± 13.2; 12 months CPAP, 10.7 ± 8.7; ASV, 6.1 ± 7.8, P < .05) and BNP levels (baseline CPAP, 686.7 ± 978.7 ng/mL; ASV, 537.3 ± 891.8; 12 months CPAP, 847.3 ± 1848.1; ASV, 230.4 ± 297.4; P < .05) significantly more effectively as compared with CPAP. There were no relevant differences in exercise performance and echocardiographic parameters between the groups. CONCLUSIONS ASV improved CSA/CSR and BNP over a 12-month period more effectively than CPAP.

The role of transbronchial cryobiopsy and surgical lung biopsy in the diagnostic algorithm of interstitial lung disease

It is not yet known if transbronchial cryobiopsy (TCB) is a reliable and safe diagnostic tool in the investigation of interstitial lung disease (ILD). To date, there have been no studies directly comparing the value of TCB with that of surgical lung biopsy (SLB). The study was initiated to determine whether the samples taken by TCB lead to a reliable diagnosis and whether SLB can be avoided in a relevant percentage of cases.

Evaluation of a Noninvasive Algorithm for Differentiation of Obstructive and Central Hypopneas

STUDY OBJECTIVES The clear discrimination of central and obstructive hypopneas is highly relevant to avoid misinterpretation and inappropriate treatment of complicated breathing patterns. Esophageal manometry is the accepted standard for the differentiation of the phenotypes of sleep apnea. However, it is limited in its use due to poor acceptance by patients and therefore rarely performed in routine clinical practice. Flattening of the inspiratory airflow curve, paradoxical breathing, arousal position, sleep stages, and breathing pattern at the end of the hypopnea can each give hints for the classification of hypopnea. The aim of this study was to evaluate a standardized algorithm combining these polysomnographic parameters for the discrimination of hypopneas in everyday practice. METHODS Polysomnography (PSG) and esophageal manometry were performed in 41 patients suspected of having sleep apnea (33 male, 52.3 ± 15.9 yr, body mass index 28.6 ± 4.5 kg/m(2)). Hypopneas were independently discriminated by blinded investigators based on esophageal pressure and the PSG-based algorithm. Only those hypopneas that could be differentiated with both methods were evaluated. RESULTS There were 1,175 of 1,837 hypopneas (64%) that could be defined by esophageal pressure, 1,812 (98.6%) by the PSG-based algorithm. Using esophageal pressure as a reference, the new algorithm correctly defined 76.9% of central and 60.5% of obstructive hypopneas. The overall accuracy was 68%. The isolated analysis of single PSG parameters revealed a lower accuracy compared with the combined algorithm. CONCLUSIONS The PSG-based algorithm allows for discrimination of most hypopneas. It is advantageous in comparison with esophageal pressure because it is noninvasive and less impaired by artefacts. Therefore, it is a potentially helpful tool for sleep specialists. CITATION Randerath WJ; Treml M; Priegnitz C; Stieglitz S; Hagmeyer L; Morgenstern C. Evaluation of a noninvasive algorithm for differentiation of obstructive and central hypopneas. SLEEP 2013;36(3):363-368.

Evaluation of a System for Transcutaneous Long-Term Capnometry

Background: The measurement of CO₂ partial pressure (PCO₂) is of great importance. Former systems of transcutaneous capnometry combining the measurement of oxygen partial pressure (PO₂) and PCO₂ had their limitations due to skin irritations caused by the heating-up of the sensor and a short application time of 4 h. Objectives: To evaluate for the first time combined monitoring of transcutaneous PCO₂ (tcPCO₂) and oxygen saturation applying a lower temperature (sensor temperature 42°C) and a new sensor technology in healthy individuals during sleep. Methods: Twenty-nine healthy individuals [12 males, age 35.2 ± 17.0 years, body height: 170.2 ± 12.0 cm (mean ± SD), weight: 76.3 ± 15.8 kg, body mass index 26.5 ± 5.4] were monitored for more than 6 h at night with the TOSCA 500 instrument (Radiometer, Basel, Switzerland). tcPCO₂ was continuously monitored and its correlation with selective measured capillary PCO₂ values (PcapCO₂) was monitored at 0.00 and 4.00 h. Results: At 0.00 h, PcapCO₂ was 37.1 ± 5.1 mm Hg and tcPCO₂ was 43.4 ± 6.6 mm Hg (p < 0.001). At 4.00 h, PcapCO₂ was 37.0 ± 5.6 mm Hg and tcPCO₂ was 43.5 ± 5.4 mm Hg (p < 0.001). PcapCO₂ and tcPCO₂ were positively and significantly correlated (0.00 h: r = 0.5, p < 0.02 and 4.00 h: r = 0.72 and p < 0.001) at both time points. In the course of the night, there was no significant drift in the tcPCO₂ values. Conclusion: The investigated system enables stable measurement of tcPCO₂ without relevant drift in healthy individuals and does not require recalibration. tcPCO₂ is highly suitable as a measure of PcapCO₂ because the two parameters are highly correlated and there is no inconvenience to the patient.

Successful Concomitant Therapy with Pirfenidone and Nintedanib in Idiopathic Pulmonary Fibrosis: A Case Report

Pirfenidone and nintedanib are both pleiotropic anti-fibrotic agents approved for the treatment of idiopathic pulmonary fibrosis (IPF) as monotherapy. To date, evidence supporting their efficacy as concomitant therapy has not been reported. Here, we present the first case of a Caucasian male patient with IPF treated with both pirfenidone and nintedanib following 2 years of treatment with pirfenidone monotherapy. Over a 24-month period, there was a clear decline in the patients forced vital capacity from 3.5 liter before initiation of treatment to 2.5 liter after 24 months. Concomitant nintedanib treatment was initiated in March 2015. Lung function stabilized, and the two treatments were well tolerated. Treatment with pirfenidone and nintedanib has currently been ongoing for nearly 12 months. This is the first report of a successful long-term treatment with pirfenidone and nintedanib and suggests that in selected cases, concomitant anti-fibrotic therapy may represent a safe and therapeutically valuable escalation option after pirfenidone monotherapy.

Fiducial marker placement via conventional or electromagnetic navigation bronchoscopy (ENB): an interdisciplinary approach to the curative management of lung cancer.

Conventional and electromagnetic navigation bronchoscopy (ENB) is generally used as a diagnostic tool in suspicious pulmonary nodules. The use of this technique for the placement of fiducial markers in patients with inoperable but early‐stage lung cancer could present an innovative approach enabling risk‐reduced therapy.

Adaptive servoventilation in clinical practice: beyond SERVE-HF?

Adaptive servoventilation (ASV) has proven effective at suppressing breathing disturbances during sleep, improving quality of life and cardiac surrogate parameters. Since the publication of the SERVE-HF-trial, ASV became restricted. The purpose of this study was to evaluate the clinical relevance of the SERVE-HF inclusion criteria in real life and estimate the portion of patients with these criteria with or without risk factors who are undergoing ASV treatment. We performed a retrospective study of all patients who were treated with ASV in a university-affiliated sleep laboratory. We reviewed the history of cardiovascular diseases, echocardiographic measurements of left ventricular ejection fraction (LVEF) and polysomnography. From 1998 to 2015, 293 patients received ASV, of which 255 (87.0%) had cardiovascular diseases and 118 (40.3%) had HF. Among those with HF, the LVEF was ≤45% in 47 patients (16.0%). Only 12 patients (4.1%) had LVEF <30%. The SERVE-HF inclusion criteria were present in 28 (9.6%) ASV recipients. Of these patients, 3 died within 30–58 months of therapy, all with systolic HF and a LVEF <30%. In this study, only a small minority of ASV patients fell in the risk group. The number of fatalities did not exceed the expected mortality in optimally treated systolic HF patients. The majority of ASV patients do not fulfil the risk criteria. Fatalities under ASV did not exceed expected figures. http://ow.ly/V2HI30fBURh

Parameters of Overnight Pulse Wave under Treatment in Obstructive Sleep Apnea

Background: Sleep-related breathing disorders may promote cardiovascular (CV) diseases. A novel and differentiated approach to overnight photoplethysmographic pulse wave analysis, which includes risk assessment and measurement of various pulse wave characteristics, has been evaluated in obstructive sleep apnea (OSA). Objectives: The purpose of this study was to assess if and which of the differentiated pulse wave characteristics might be influenced by OSA treatment with positive airway pressure (PAP). Methods: The study included two protocols. In the case-control study (group A), pulse wave-derived CV risk indices recorded during PAP therapy were compared with those obtained in age, body mass index, and CV risk class-matched patients with untreated OSA (n = 67/67). In the prospective PAP treatment study (group B), 17 unselected patients undergoing a full-night sleep test at baseline and after 23 ± 19 weeks of treatment were analyzed. Results: In untreated OSA patients (group A), the overnight hypoxic load was increased (SpO2 index 38.7 ± 17.5 vs. 24.0 ± 11.1, p < 0.001) and the pulse wave attenuation index (PWA-I) was lower (29.4 ± 9.2 vs. 33.5 ± 11.8, p = 0.022) than in treated patients. In group B, PAP therapy reduced the hypoxic load and increased the PWA-I significantly. The composite CV risk index was slightly but not significantly reduced. Conclusions: PAP therapy modified the hypoxic load and pulse wave-derived markers. The PWA-I - associated with sympathetic vascular tone - was most prominently modified by PAP. This novel approach to markers of CV function should be further evaluated in prospective studies.

Hypoxie in der Flugsimulation bei adipösen Patienten

Einleitung: Die Druckverhaltnisse in einem Flugzeug auf Reiseflughohe fuhren zu verringertem O2-Partialdruck und damit zum Abfall der Blutsauerstoffsattigung. Fraglich ist, wie ausgepragt bei adiposen Patienten (BMI≥30 kg/m2) eine Hypoxie in der Flugsituation ist und wie dies durch eine COPD beeinflusst wird. Fraglich ist auch, ob unterschiedliche Testmethoden vergleichbar sind. Methoden: Die Untersuchungen umfassten Bodyplethysmografie, 6-min-/50 m-Gehtest und Blutgasanalysen. Anschliesend wurden Flugbedingungen unter normobaren Bedingungen (Hypoxia Altitude Simulation Test, HAST, Atmung von 15,1% O2) sowie hypobaren Verhaltnissen (Hypobaric Chamber Test „HCT“, 760mbar) simuliert. Ergebnisse: 8 Lungengesunde (4 m, 42 ± 9 Jahre, BMI 36 ± 4 kg/m2) und 9 COPD-Patienten (6 m, 59 ± 13 Jahre, BMI 33 ± 3 kg/m2) wurden untersucht. Erstere zeigten eine normale Lungenfunktion und Leistungsfahigkeit (6-MWD 555 ± 43 m, 50 m-Gehzeit 28 ± 4 s) bei durchweg guter O2-Sattigung und normalen BGA-Werten (in Ruhe: SpO2 98 ± 1%, PaO2 81 ± 9 mmHg, PaCO2 38 ± 4 mmHg; post-6-MWT: SpO2 97 ± 1%, PaO2 92 ± 7 mmHg, PaCO2 36 ± 3 mmHg). Die COPD-Patienten zeigten eine eingeschrankte Lungenfunktion (FEV1 60 ± 20% Soll, FEV1/FVC 56 ± 12%) bei reduzierter Leistungsfahigkeit (6-MWD 458 ± 78 m, 50 m-Gehzeit 35 ± 6 s) und leicht eingeschrankten Blutgasen (in Ruhe: SpO2 94 ± 2%, PaO2 67 ± 10 mmHg, PaCO2 37 ± 3 mmHg; post-6-MWT: SpO2 93 ± 5%, PaO2 75 ± 11 mmHg, PaCO2 36 ± 4 mmHg). Die O2-Werte unter HAST und HCT waren innerhalb der Gruppen weitgehend vergleichbar. Die lungengesunden Probanden zeigten O2-Sattigungen ≥90% ohne Substitutionsbedarf. Insbesondere bei den COPD-Patienten zeigten sich Abfalle im HCT und im HAST. Diskussion: Die Moglichkeit, die Flugtauglichkeit mittels HCT oder HAST bei Probanden mit Adipositas Grad I-II sowie bei zusatzlicher COPD zu prufen, scheint vergleichbar. Insbesondere Patienten mit schwerer COPD profitieren von einem HCT, um die Schwere der zu erwartenden Entsattigung auf Flughohe festzustellen.

Complications in transbrochial cryobiopsy (TCB)

Background: TCB is an endoscopic tissue sampling technique gaining importance in diagnosis of interstitial lung diseases (ILD). It remains unclear whether this method is sufficiently safe in clinical routine. Methods: We present preliminary data from a prospective, observational study, examining patients with idiopathic interstitial pneumonia (IIP). Patients with differential diagnosis of NSIP/IPF or unclassifiable ILD according to HRCT underwent TCB. Lung function, histological results and peri-interventional complications were documented. Results: Until now, data from 19 ILD patients were evaluated (7 f, 66±11 y, BMI 27.7±3.2 kg/m²). Mean values showed slightly restricted ventilation and impaired gas exchange (TLC 73±19%pred, FVC 80±16%pred, DLCO 61±13%pred, DLCO/VA 91±16%pred). 3 patients needed post-interventional intensive care due to sedation hangover. Bleeding occurred in 7 (moderate) and 8 patients (severe, BTS 2013 classification) and could be stopped with Xylometazoline or Adrenaline. In 5 patients a pneumothorax occurred (4 of them with drainage need). In 2 patients myocardial infarction developed after >24 hours, confirmed via coronary angiography and apparently being a primary manifestation of coronary heart disease. 1 patient died of acute ILD exacerbation (histologically probable UIP pattern). Considering previous data mortality after TCB is 0.7%, after surgical lung biopsy 3.3% Conclusion: Until now, TCB in IIP patients is still being established in clinical routine. There is probably a relevant procedure-associated risk despite of sufficient lung functional reserve. Currently, a risk constellation for the occurrence of complications cannot be identified. Mortality after TCB is probably lower than after surgical lung biopsy.