Stephan Budweiser

Sleep Apnea is an Independent Correlate of Erectile and Sexual Dysfunction

INTRODUCTION Obstructive sleep apnea (OSA) has been linked with erectile dysfunction (ED), but it is unknown whether this association is maintained in the presence of other risk factors for ED. AIM The aim of this study was to evaluate the relationship between ED/sexual dysfunction and polysomnographic measures of sleep apnea in patients with known risk factors for ED. METHODS Prospective cross-sectional analysis of 401 male patients undergoing in-lab polysomnography for suspected OSA. Erectile (EF) and sexual function were assessed by the 15-item International Index of Erectile Function (IIEF-15) questionnaire. MAIN OUTCOME MEASURES Severity of OSA via apnea-hypopnea index (AHI) and mean/lowest nocturnal oxygen saturation (SaO(2)). The IIEF-15 including the sexual domains: EF, intercourse satisfaction, orgasmic function, sexual desire, and overall satisfaction. RESULTS OSA (AHI > 5/h) was diagnosed in 92% of patients. ED (EF subdomain < or = 25) was present in 69% of patients with, and 34% of patients without OSA (P < 0.001). Multivariate stepwise regression analyses including known risk factors for ED, such as age, obesity, coronary heart disease, peripheral occlusive disease, hypertension, diabetes, prostate surgery, and beta-blocker treatment, and measures of sleep apnea identified mean nocturnal SaO(2) as independently associated with ED (P = 0.002; mean [95% CI] normalized slope 0.126 [0.047; 0.205]). Age (P < 0.001), peripheral occlusive disease (P = 0.001), prostate surgery (P = 0.018), and hypertension (P = 0.021) were confirmed as risk factors for ED, but did not abolish the sleep apnea-associated risk. Similar results were obtained for sexual dysfunction. Logistic regression analysis using the diagnosis of ED (EF subdomain < or = 25) as binary dependent variable confirmed that mean nocturnal SaO(2) (P = 0.012), as well as age (P < 0.001) were independently associated with ED. CONCLUSIONS ED and overall sexual dysfunction were highly prevalent in patients with suspected OSA. Irrespective of known risk factors, mean nocturnal SaO(2) was an additional, independent correlate of these dysfunctions, suggesting that OSA-related intermittent nocturnal hypoxemia specifically contributes to their development.

Impact of noninvasive home ventilation on long‐term survival in chronic hypercapnic COPD: a prospective observational study

Aims:  The long‐term benefit from noninvasive ventilation (NIV) in chronic hypercapnic chronic obstructive pulmonary disease (COPD) remains uncertain.

The Severe Respiratory Insufficiency Questionnaire was valid for COPD patients with severe chronic respiratory failure

OBJECTIVES The Severe Respiratory Insufficiency (SRI) Questionnaire has recently been developed and validated for the assessment of health-related quality of life (HRQL) in patients with severe chronic respiratory failure resulting from a broad spectrum of underlying disorders. The present study was aimed at reexamining the internal structure of the SRI specifically for chronic obstructive pulmonary disease (COPD) patients. STUDY DESIGN AND SETTING Cross-validation was performed in two COPD groups (N=78 and N=84), each receiving home mechanical ventilation in addition to long-term oxygen therapy. The internal consistency reliability was calculated using Cronbachs alpha coefficient. Explorative Factor Analysis was performed followed by Confirmatory Factor Analysis to establish construct validity. RESULTS In the total group (N=162) Cronbachs alpha ranged from 0.73 to 0.88. Only one factor could be established which explained 58.5% of the total variance confirming one Summary Scale (SRI-SS). For each of the seven subscales, Confirmatory Factor Analysis revealed two factors, which were substantially correlated (r=0.43-0.80). All scale scores covered a broad range of the questionnaires scaling range (0-100). The mean SRI-SS score was 52+/-17 indicating a homogenous scaling distribution. CONCLUSION The SRI is a multidimensional and highly specific tool with high psychometric properties for HRQL assessment in COPD patients with severe chronic respiratory failure.

Health-related quality of life and long-term prognosis in chronic hypercapnic respiratory failure: a prospective survival analysis

BackgroundHealth-related quality of life (HRQL) is considered as an important outcome parameter in patients with chronic diseases. This study aimed to assess the role of disease-specific HRQL for long-term survival in patients of different diagnoses with chronic hypercapnic respiratory failure (CHRF).MethodsIn a cohort of 231 stable patients (chronic obstructive pulmonary disease (COPD), n = 98; non-COPD (obesity-hypoventilation syndrome, restrictive disorders, neuromuscular disorders), n = 133) with CHRF and current home mechanical ventilation (HMV), HRQL was assessed by the disease-specific Severe Respiratory Insufficiency (SRI) questionnaire and its prognostic value was prospectively evaluated during a follow-up of 2–4 years, using univariate and multivariate regression analysis.ResultsHRQL was more impaired in COPD (mean ± SD SRI-summary score (SRI-SS) 52.5 ± 15.6) than non-COPD patients (67.6 ± 16.4; p < 0.001). Overall mortality during 28.9 ± 8.8 months of follow-up was 19.1% (31.6% in COPD, 9.8% in non-COPD). To identify the overall role of SRI, we first evaluated the total study population. SRI-SS and its subdomains (except attendance symptoms and sleep), as well as body mass index (BMI), leukocyte number and spirometric indices were associated with long-term survival (p < 0.01 each). Of these, SRI-SS, leukocytes and forced expiratory volume in 1 s (FEV1) turned out to be independent predictors (p < 0.05 each). More specifically, in non-COPD patients SRI-SS and most of its subdomains, as well as leukocyte number, were related to survival (p < 0.05), whereas in patients with COPD only BMI and lung function but not SRI were predictive.ConclusionIn patients with CHRF and HMV, the disease-specific SRI was an overall predictor of long-term survival in addition to established risk factors. However, the SRI predominantly beared information regarding long-term survival in non-COPD patients, while in COPD patients objective measures of the disease state were superior. This on one hand highlights the significance of HRQL in the long-term course of patients with CHRF, on the other hand it suggests that the predictive value of HRQL depends on the underlying disease.

Treatment of respiratory failure in COPD

Patients with advanced COPD and acute or chronic respiratory failure are at high risk for death. Beyond pharmacological treatment, supplemental oxygen and mechanical ventilation are major treatment options. This review describes the physiological concepts underlying respiratory failure and its therapy, as well as important treatment outcomes. The rationale for the controlled supply of oxygen in acute hypoxic respiratory failure is undisputed. There is also a clear survival benefit from long-term oxygen therapy in patients with chronic hypoxia, while in mild, nocturnal, or exercise-induced hypoxemia such long-term benefits appear questionable. Furthermore, much evidence supports the use of non-invasive positive pressure ventilation in acute hypercapnic respiratory failure. It application reduces intubation and mortality rates, and the duration of intensive care unit or hospital stays, particularly in the presence of mild to moderate respiratory acidosis. COPD with chronic hypercapnic respiratory failure became a major indication for domiciliary mechanical ventilation, based on pathophysiological reasoning and on data regarding symptoms and quality of life. Still, however, its relevance for long-term survival has to be substantiated in prospective controlled studies. Such studies might preferentially recruit patients with repeated hypercapnic decompensation or a high risk for death, while ensuring effective ventilation and the patients’ adherence to therapy.

Long-Term Changes of Sexual Function in Men with Obstructive Sleep Apnea after Initiation of Continuous Positive Airway Pressure

INTRODUCTION Obstructive sleep apnea (OSA), particularly intermittent nocturnal hypoxemia, is associated with erectile dysfunction (ED). AIM We investigated in patients with OSA whether continuous positive airway pressure (CPAP) therapy has a long-term effect on sexual function, including ED, in the presence of other risk factors for ED. METHODS Within a long-term observational design, we reassessed 401 male patients who had been referred for polysomnography, with respect to erectile and overall sexual function. Mean ± standard deviation follow-up time was 36.5 ± 3.7 months. Patients with moderate to severe ED were stratified according to the regular use of CPAP. MAIN OUTCOME MEASURE Changes of sexual function were assessed by the 15-item International Index of Erectile Function (IIEF-15) questionnaire, including the domains erectile function (EF), intercourse satisfaction, orgasmic function (OF), sexual desire (SD), and overall satisfaction (OS). RESULTS Of the 401 patients, 91 returned a valid IIEF-15 questionnaire at follow-up. Their baseline characteristics were not different from those of the total study group. OSA (apnea-hypopnea index >5/hour) had been diagnosed in 91.2% of patients. In patients with moderate to severe ED (EF domain <17), CPAP users (N = 21) experienced an improvement in overall sexual function (IIEF-15 summary score; P = 0.014) compared with CPAP non-users (N = 18), as well as in the subdomains OF (P = 0.012), SD (P = 0.007), and OS (P = 0.033). Similar results were obtained in patients with poor overall sexual dysfunction (IIEF-15 summary score <44). In patients with moderate to severe ED and low mean nocturnal oxygen saturation (≤93%, median), also the EF subdomain improved in CPAP users vs. non-users (P = 0.047). CONCLUSIONS These data indicate that long-term CPAP treatment of OSA and the related intermittent hypoxia can improve or preserve sexual function in men with OSA and moderate to severe erectile or sexual dysfunction, suggesting a certain reversibility of OSA-induced sexual dysfunctions.

Impact of Ventilation Parameters and Duration of Ventilator Use on Non-Invasive Home Ventilation in Restrictive Thoracic Disorders

Background: Non-invasive positive pressure ventilation (NPPV) is an accepted treatment option for chronic ventilatory failure due to restrictive thoracic disorders. Objective: The impact of ventilation setting and the duration of ventilator use on changes in physiological and functional parameters has not yet been evaluated. Methods: Effects of NPPV on body plethysmographic parameters, blood gas tension and inspiratory muscle function up to 12 months were analyzed in 44 patients with thoracic cage abnormalities in a clinical stable condition. Furthermore, the influence of ventilator parameters and the duration of ventilator use on these changes was determined. Results: A significant improvement in blood gas parameters (PaCO2, PaO2 and base excess; p < 0.001), lung volumes (VC, TLC and FEV1; p < 0.001) and inspiratory muscle function (PImax, P0.1; p < 0.01 and p < 0.05) was found after 3.8 ± 0.8 months of treatment. As shown by a subgroup analysis, changes were already achieved within the first 3 months of NPPV and then remained stable over time. Improvements in VC were positively correlated with IPAP (r = 0.55; p < 0.001). Reduction in PaCO2 was positively correlated with the quotient (IPAP – EPAP)/weight (r = 0.55; p < 0.001). No correlation could be detected between changes in functional parameters and the duration of ventilator use. Conclusions: NPPV can improve blood gas parameters, lung volume and inspiratory muscle function in thoracic restrictive disorders. To best utilize the potential of NPPV treatment, it seems to be more effective to optimize pressure levels than to extend the duration of ventilation.

Pulmonary hypertension in obesity-hypoventilation syndrome

BACKGROUND Pulmonary hypertension (PH) is considered a clinically important feature of Obesity-Hypoventilation Syndrome (OHS). We aimed to determine prevalence, characteristics and severity of PH including associations with clinical outcomes after established non-invasive positive pressure ventilation (NPPV). METHODS In a prospective cross-sectional study, clinically stable OHS-patients (NPPV duration ≥ 3 months) were consecutively assessed using echocardiography, serum markers and right-heart catheterization (RHC). NPPV use was quantified via ventilator counters. Blood gases, lung function, Epworth-Sleepiness Scale (ESS), sleep-quality, WHO-functional class (WHO-FC), 6-min walk distance, and health-related quality of life (HRQL) via Severe Respiratory Insufficiency (SRI) questionnaire were assessed. RESULTS Of 177 patients considered, 64 fulfilled inclusion criteria. Among these, 21 patients (10 female/11 male; BMI 45 [40; 53] kg/m(2), PaCO2 39.6 [37.8; 45.5] mmHg (median [quartiles])) gave consent for RHC. Four patients (19%) had normal mean pulmonary artery pressure (mPAP < 20 mmHg), 8 (38.1%) mPAP 20-24 mmHg and 9 (42.9%) manifest PH (mPAP ≥ 25 mmHg), 3 of them with combined pre- and/or postcapillary PH. mPAP was negatively correlated to NPPV use, vital capacity and lung diffusing capacity (p < 0.01 each), and positively to BMI (p < 0.05). NPPV use and vital capacity independently predicted mPAP. In patients with PH, ESS, WHO-FC, and some SRI-items were worse (p < 0.05 each) compared to patients without PH. Multivariate analyses revealed mPAP as the only independent predictor of the SRI-physical functioning domain. CONCLUSIONS Mild to moderate PH is frequent in patients with OHS despite NPPV, mPAP being inversely related to NPPV adherence. PH is associated with impairments in daytime-sleepiness, WHO-FC, HRQL and physical functioning.

Predictive Significance of the Six-Minute Walk Distance for Long-Term Survival in Chronic Hypercapnic Respiratory Failure

Background: The 6-min walk distance (6-MWD) is a global marker of functional capacity and prognosis in chronic obstructive pulmonary disease (COPD), but less explored in other chronic respiratory diseases. Objective: To study the role of 6-MWD in chronic hypercapnic respiratory failure (CHRF). Methods: In 424 stable patients with CHRF and non-invasive ventilation (NIV) comprising COPD (n = 197), restrictive diseases (RD; n = 112) and obesity-hypoventilation-syndrome (OHS; n = 115), the prognostic value of 6-MWD for long-term survival was assessed in relation to that of body mass index (BMI), lung function, respiratory muscle function and laboratory parameters. Results: 6-MWD was reduced in patients with COPD (median 280 m; quartiles 204/350 m) and RD (290 m; 204/362 m) compared to OHS (360 m; 275/440 m; p < 0.001 each). Overall mortality during 24.9 (13.1/40.5) months was 22.9%. In the 424 patients with CHRF, 6-MWD independently predicted mortality in addition to BMI, leukocytes and forced expiratory volume in 1 s (p < 0.05 each). In COPD, 6-MWD was strongly associated with mortality using the median [p < 0.001, hazard ratio (HR) = 3.75, 95% confidence interval (CI): 2.24–6.38] or quartiles as cutoff levels. In contrast, 6-MWD was only significantly associated with impaired survival in RD patients when it was reduced to 204 m or less (1st quartile; p = 0.003, HR = 3.31, 95% CI: 1.73–14.10), while in OHS 6-MWD had not any prognostic value. Conclusions: In patients with CHRF and NIV, 6-MWD was predictive for long-term survival particularly in COPD. In RD only severely reduced 6-MWD predicted mortality, while in OHS 6-MWD was relatively high and had no prognostic value. These results support a disease-specific use of 6-MWD in the routine assessment of patients with CHRF.

Hemoglobin Levels Above Anemia Thresholds Are Maximally Predictive for Long-Term Survival in COPD With Chronic Respiratory Failure

BACKGROUND: In patients with COPD, chronic anemia is known as an unfavorable prognostic factor. Whether the association between hemoglobin (Hb) levels and long-term survival is restricted to anemia or extends to higher Hb levels has not yet been systematically assessed. METHODS: We determined Hb levels in 309 subjects with COPD and chronic respiratory failure prior to initiation of noninvasive ventilation, accounting for confounders that might affect Hb. Subjects were categorized as anemic (Hb < 12 g/dL in females, Hb < 13 g/dL in males), polycythemic (Hb ≥ 15 g/dL in females, Hb ≥ 17 g/dL in males), or normocythemic. In addition, percentiles of Hb values were analyzed with regard to mortality from any cause. RESULTS: Two-hundred seven subjects (67.0%) showed normal Hb levels, 46 (14.9%) had anemia, and 56 (18.1%) had polycythemia. Polycythemic subjects showed a higher survival rate than anemic (P = .01) and normocythemic subjects (P = .043). In a univariate Cox hazards model, Hb was associated with long-term survival (hazard ratio 0.855; 95% CI 0.783–0.934, P < .001). The 58th percentiles of Hb (14.3 g/dL in females, 15.1 g/dL in males) yielded the highest discriminative value for predicting survival (hazard ratio 0.463, 95% CI 0.324–0.660, P < .001). In the multivariate analysis this cutoff was an independent predictor for survival (hazard ratio 0.627, 95% CI 0.414–0.949, P = .03), in addition to age and body mass index. CONCLUSIONS: In subjects with COPD and chronic respiratory failure undergoing treatment with noninvasive ventilation and LTOT, high Hb levels are associated with better long-term survival. The optimal cutoff level for prediction was above the established threshold defining anemia. Thus, predicting survival only on the basis of anemia does not fully utilize the prognostic potential of Hb values in COPD.