Appareils à pression positive continue pour le traitement de l'apnée obstructive du sommeil / Continuous positive airway pressure devices for the treatment of obstructive sleep apnea

MANDAT: L'Institut national d'excellence en santé et en services sociaux (INESSS) a reçu le mandat de la Direction générale des affaires universitaires, médicales, infirmières et pharmaceutiques (DGAUMIP) du ministère de la Santé et des Services sociaux (MSSS) de produire un état des connaissances sur les politiques publiques de remboursement d'appareils à pression positive continue (PPC) pour le traitement de l'apnée obstructive du sommeil (AOS). MÉTHODE: Une revue rapide de la littérature et des démarches participatives pour une collecte de données contextuelles et expérientielles ont été réalisées sur les appareils à PPC pour le traitement de l'AOS. Une analyse d'impact budgétaire a été effectuée par l'INESSS. MISE EN CONTEXTE: L'AOS est symptomatique lorsque l'occlusion des voies respiratoires supérieures (VRS) et l'augmentation de l'effort respiratoire surviennent conjointement avec un sommeil non réparateur. Bien que la prévalence réelle demeure incertaine au Québec, les données de la littérature suggèrent que près de 39 % de la population générale serait atteinte de l'AOS. Au Québec, la prise en charge de cette condition comprend : l'identification des symptômes par des cliniciens; l'épreuve de sommeil; le diagnostic; le choix du traitement en concertation entre le patient et les professionnels de la santé; et l'accompagnement des patients. Selon les cliniciens consultés, la stratégie de diagnostic se base davantage sur l'évaluation des symptômes que sur la mesure de la sévérité de la maladie (légère, modérée ou sévère) à l'aide de différentes épreuves du sommeil. Cependant, près de 80 % des personnes atteintes demeureraient sans diagnostic. Celles qui détiennent une assurance privée ou qui bénéficient d'une assistance sociale ont une couverture pour les appareils à PPC. Toutefois, certaines personnes se trouvent sans couverture. Afin de bonifier l'accessibilité du traitement, le ministre de la Santé et des Services sociaux du Québec a annoncé en avril 2023 une mesure de financement annuelle pour le remboursement des appareils à PPC. Les modalités de cette mesure de remboursement ne sont pas encore définies. LE TRAITEMENT PAR PRESSION POSITIVE CONTINUE: Les appareils à PPC poussent de l'air de façon non effractive dans les VRS sans interférer avec le réflexe respiratoire naturel afin de maintenir la constance de la pression d'air durant la nuit. Au Québec, les appareils à PPC constituent le traitement indiqué pour la majorité des adultes et certains enfants qui ont reçu un diagnostic d'AOS. Les cliniciens consultés ont jugé plausibles les données de la littérature qui rapportent que 57 % des patients adultes adhèrent adéquatement au traitement par PPC. Le succès du traitement dépend, entre autres, de la qualité de l'accompagnement par les professionnels de la santé et du suivi par télésurveillance de l'adhésion des patients au traitement par PPC. COUVERTURE PUBLIQUE DANS D'AUTRES PAYS ET TERRITOIRES: Deux modèles de prestations concernant les appareils à PPC ont été repérés dans la littérature grise. Dans certains pays et territoires, le modèle de prestation conjointe publique et privée finance partiellement et à des intervalles réguliers l'achat de l'appareil et de certains accessoires. Ce modèle soutient l'accès au traitement et dissocie les parties médicale et technique de la prestation des soins. Pour d'autres pays et territoires, le modèle de prestation publique couvre complètement le suivi médical, l'accompagnement du patient et le prêt d'équipement. POPULATION CIBLE ET ANALYSE ÉCONOMIQUE: L'analyse d'impact budgétaire réalisée par l'INESSS vise à quantifier l'impact financier attendu à la suite de l'implantation d'une politique publique de remboursement des appareils à PPC pour le traitement de l'AOS. Le coût net par patient adulte sur 5 ans est estimé à 4 505 $, alors que ce coût par patient en pédiatrie est estimé à 8 847 $. En fonction de la population ciblée, le volume de patients (impact budgétaire) sur 5 ans est estimé à 354 884 personnes avec une couverture de la population totale (1 408,3 M$), au moins 92 270 personnes non assurées (366,1 M$) ou 24 198 personnes à faibles revenus qui ne sont pas couvertes par l'assistance sociale du Québec (96,0 M$). Il est estimé que l'impact financier annuel croitra de près de 45 % sur 5 ans, principalement en raison du renouvellement des accessoires. ÉLÉMENTS À CONSIDÉRER POUR L'IMPLANTATION: Selon les consultations menées par l'INESSS, l'introduction d'une politique publique au Québec doit tenir compte des ressources actuellement limitées des établissements de santé. L'intégration du secteur privé dans cette politique devrait également tenir compte des pratiques spécifiques à ce secteur. Plusieurs autres éléments pourraient faire partie de la réflexion, tels que : la priorisation de certains groupes de patients; l'importance du sous-diagnostic; l'accès au du traitement; les critères d'accès au remboursement; et les accessoires et services inclus dans la prestation. CONCLUSION: Cet état des connaissances brosse le portrait de la prise en charge de l'apnée du sommeil par appareils à PPC au Québec et explore les enjeux potentiels liés à l'implantation d'une politique de couverture publique complète ou partielle. Selon les objectifs, certains paramètres devront être définis afin d'assurer le maximum d'avantages pour les patients. De plus, des incertitudes liées à la disponibilité des ressources et à l'organisation des services entourant ce remboursement au Québec ont été mises en lumière et pourraient être un frein à une implantation optimale.

MANDATE: The Institut national d'excellence en santé et en services sociaux (INESSS) was mandated by the Direction générale des affaires universitaires, médicales, infirmières et pharmaceutiques (DGAUMIP) of the Ministère de la Santé et des Services sociaux (MSSS) to produce a state-of-knowledge report on the public remboursement policies for continuous positive airway pressure (CPAP) treatment of obstructive sleep apnea (OSA). METHOD: The approach includes a rapid review of the scientific literature and a participatory process to collect contextual and experiential data for the treatment of OSA with CPAP. A budgetary impact analysis was also performed. CONTEXT AND SETTING: OSA is considered symptomatic when blocked upper airways and increased respiratory effort occur in conjunction with non-restorative sleep. Although the actual prevalence of OSA remains uncertain in Quebec, literature data suggests that nearly 39% of the general population is affected by OSA. In Quebec, OSA care includes identification of symptoms by a sleep medical doctor; sleep tests and patient diagnostic; treatment choice through collaboration between the patient and health professionals; and treatment support. According to the clinicians consulted, the diagnostic strategy is based more on the evaluation of symptoms than on measuring the severity of the disease (mild, moderate or severe) using different sleep tests. However, its estimated that nearly 80% of adults with OSA are not diagnosed. For coverage of expenses related to the CPAP device, it is estimated that 74% of diagnosed patients have a private insurance and 3.1% benefit from social assistance. The remaining patients currently have no coverage. To improve access to treatment, the Ministre de la Santé et des Services sociaux du Québec announced in April 2023 a measure, with recurring funding, for the reimbursement of CPAP devices. Terms and conditions of this reimbursement measure are not yet defined. POSITIVE PRESSURE TREATMENT: CPAP devices push air into the upper airways without interfering with the natural respiratory reflex. In Quebec, CPAP devices are the main indication for the treatment of adults and children with OSA. The adherence to CPAP treatment is about 57% amid adult patients, based on literature data that was confirmed by the clinicians consulted in this report. Treatment success depends, in part, on the quality of support provided by healthcare professionals and the telemonitoring of treatment adherence. PUBLIC COVERAGE IN OTHER COUNTRIES AND TERRITORIES: Two reimbursement models for CPAP devices have been identified in the literature. In some countries and territories, a joint public-private model partially funds the CPAP device and accessory purchases. This model covers access to treatment and separates the medical and technical parts of care delivery. Whereas in other countries and territories, a public model fully covers medical follow-up, patient support and equipment loans. TARGET POPULATION AND ECONOMIC ANALYSIS: A budgetary impact analysis was carried out by INESSS to quantify the expected financial impact of a public policy reimbursing CPAP devices for the treatment of OSA. The net cost per adult patient is estimated at $4,505 over 5 years, whereas this cost per pediatric patient is estimated at $8,847. Depending on the target population, the volume of patients (budgetary impact) over 5 years is estimated as follows: 354,884 individuals with coverage across the entire population ($1,408.3 million), at least 92,270 uninsured individuals ($366.1 million), or 24,198 low-income individuals not covered by Quebec's social assistance ($96.0 million). The annual financial impact is estimated to increase by nearly 45% over 5 years, primarily due to accessory replacements. IMPLEMENTATION CONSIDERATIONS: According to the consultations carried out by INESSS, the introduction of a reimbursement policy in Quebec must consider the currently limited resources of healthcare facilities. The best practices in industry should also define the role of the private sector in the upcoming policy. Other elements that should be considered include prioritization of certain patient groups; significant under-diagnosis; treatment accessibility; reimbursement access criteria; and accessories and services included in the benefit. CONCLUSION: This state-of-knowledge report describes OSA care in Quebec and identifies the potential issues involved in implementing a public policy with a full or partial coverage for CPAP treatment. Depending on the objectives and the preferred approach, various parameters of this upcoming policy will need to be defined to ensure maximum benefit for patients. In addition, some uncertainties related to the availability of resources and the organization of services surrounding this reimbursement in Quebec have been highlighted and could hinder optimal implementation.

Conceptual model of low-cost improvised bubble continuous positive airway pressure device for adults and its potential use in the COVID-19 pandemic.

Low-cost improvised continuous positive airway pressure (CPAP) device is safe and efficacious in neonatal respiratory distress. There is a great necessity for similar device in adults, and this has been especially made apparent by the recent Coronavirus Disease 2019 (COVID-19) pandemic, which is unmasking the deficiencies of healthcare system in several low-resource countries. We propose a simplified and inexpensive model of improvised CPAP in adults using locally available resources including aquarium air pumps and a novel pressure release mechanism. Although the safety and efficacy of improvised CPAP in adults are not established, the conceptual model we propose has the potential to serve as a lifesaving technology in many low-resource settings during this ongoing pandemic and thus calls for expedited research.

Optimal NIV Medicare Access Promotion: Patients With Central Sleep Apnea: A Technical Expert Panel Report From the American College of Chest Physicians, the American Association for Respiratory Care, the American Academy of Sleep Medicine, and the American Thoracic Society.

This document summarizes suggestions of the central sleep apnea (CSA) Technical Expert Panel working group. This paper shares our vision for bringing the right device to the right patient at the right time. For patients with CSA, current coverage criteria do not align with guideline treatment recommendations. For example, CPAP and oxygen therapy are recommended but not covered for CSA. On the other hand, bilevel positive airway pressure (BPAP) without a backup rate may be a covered therapy for OSA, but it may worsen CSA. Narrow coverage criteria that require near elimination of obstructive breathing events on CPAP or BPAP in the spontaneous mode, even if at poorly tolerated pressure levels, may preclude therapy with BPAP with backup rate or adaptive servoventilation, even when those devices provide demonstrably better therapy. CSA is a dynamic disorder that may require different treatments over time, sometimes switching from one device to another; an example is switching from BPAP with backup rate to an adaptive servoventilation with automatic end-expiratory pressure adjustments, which may not be covered. To address these challenges, we suggest several changes to the coverage determinations, including: (1) a single simplified initial and continuing coverage definition of CSA that aligns with OSA; (2) removal of hypoventilation terminology from coverage criteria for CSA; (3) all effective therapies for CSA should be covered, including oxygen and all PAP devices with or without backup rates or servo-mechanisms; and (4) patients shown to have a suboptimal response to one PAP device should be allowed to add oxygen or change to another PAP device with different capabilities if shown to be effective with testing.

Optimal NIV Medicare Access Promotion: Patients With Thoracic Restrictive Disorders: A Technical Expert Panel Report From the American College of Chest Physicians, the American Association for Respiratory Care, the American Academy of Sleep Medicine, and the American Thoracic Society.

The existing coverage criteria for noninvasive ventilation (NIV) do not recognize the benefits of early initiation of NIV for those with thoracic restrictive disorders and do not address the unique needs for daytime support as the patients progress to ventilator dependence. This document summarizes the work of the thoracic restrictive disorder Technical Expert Panel working group. The most pressing current coverage barriers identified were: (1) delays in implementing NIV treatment; (2) lack of coverage for many nonprogressive neuromuscular diseases; and (3) lack of clear policy indications for home mechanical ventilation (HMV) support in thoracic restrictive disorders. To best address these issues, we make the following key recommendations: (1) given the need to encourage early initiation of NIV with bilevel positive airway pressure devices, we recommend that symptoms be considered as a reason to initiate therapy even at mildly reduced FVCs; (2) broaden CO2 measurements to include surrogates such as transcutaneous, end-tidal, or venous blood gas; (3) expand the diagnostic category to include phrenic nerve injuries and disorders of central drive; (4) allow a bilevel positive airway pressure device to be advanced to an HMV when the vital capacity is < 30% or to address severe daytime respiratory symptoms; and (5) provide additional HMV when the patient is ventilator dependent with use > 18 h per day. Adoption of these proposed recommendations would result in the right device, at the right time, for the right type of patients with thoracic restrictive disorders.

Continuous Positive Airway Pressure (CPAP) face-mask ventilation is an easy and cheap option to manage a massive influx of patients presenting acute respiratory failure during the SARS-CoV-2 outbreak: A retrospective cohort study.

INTRODUCTION: Because of the COVID-19 pandemic, intensive care units (ICU) can be overwhelmed by the number of hypoxemic patients. MATERIAL AND METHODS: This single centre retrospective observational cohort study took place in a French hospital where the number of patients exceeded the ICU capacity despite an increase from 18 to 32 beds. Because of this, 59 (37%) of the 159 patients requiring ICU care were referred to other hospitals. From 27th March to 23rd April, consecutive patients who had respiratory failure or were unable to maintain an SpO2 > 90%, despite receiving 10-15 l/min of oxygen with a non-rebreather mask, were treated by continuous positive airway pressure (CPAP) unless the ICU physician judged that immediate intubation was indicated. We describe the characteristics, clinical course, and outcomes of these patients. The main outcome under study was CPAP discontinuation. RESULTS: CPAP was initiated in 49 patients and performed out of ICU in 41 (84%). Median age was 65 years (IQR = 54-71) and 36 (73%) were men. Median respiratory rate before CPAP was 36 (30-40) and median SpO2 was 92% (90-95) under 10 to 15 L/min oxygen flow. Median duration of CPAP was 3 days (IQR = 1-5). Reasons for discontinuation of CPAP were: intubation in 25 (51%), improvement in 16 (33%), poor tolerance in 6 (12%) and death in 2 (4%) patients. A decision not to intubate had been taken for 8 patients, including the 2 who died while on CPAP. Two patients underwent less than one hour CPAP for poor tolerance. In the end, 15 (38%) out of 39 evaluable patients recovered with only CPAP whereas 24 (62%) were intubated. CONCLUSIONS: CPAP is feasible in a non-ICU environment in the context of massive influx of patients. In our cohort up to 1/3 of the patients presenting with acute respiratory failure recovered without intubation.

Quick Thinking Turns out Low-Cost Ventilators.

As the number of coronavirus 2019 disease (COVID-19) cases in the United States began mounting in the early weeks of March, health care workers raised the alarm about a looming shortage of ventilators to treat patients. On March 30, 2020, Ford Motor Company announced plans to produce 50,000 ventilators in 100 days [1], and General Motors followed suit on April 8, stating that it would deliver out 6,000 ventilators by the end of May and another 24,000 by August [2].

The economic and societal burden of excessive daytime sleepiness in patients with obstructive sleep apnea.

Excessive daytime sleepiness (EDS) is common in patients with obstructive sleep apnea (OSA) and continues to persist in many patients despite adequate OSA treatment. EDS in OSA is associated with decreased quality of life (QOL) as well as increased societal burden, which may impact health care utilization and costs. However, economic burden is often not the primary focus in the treatment of EDS in OSA. This targeted literature review aimed to examine the published literature on the economic burden of EDS in OSA. This review identified available literature using a targeted PubMed search strategy using search terms related to EDS in OSA in adults. Results demonstrate that there are few studies that detailed the direct costs associated with EDS in OSA, though several studies indicated an association between EDS in OSA and indirect economic burdens, including motor vehicle accidents (MVAs), near misses, work productivity, mood, and QOL. Data from the literature confirmed that persistent EDS in OSA following continuous positive airway pressure persists in 12%-65% of patients. Future studies should further describe the direct costs of EDS in OSA, quantify the cost associated with MVAs and lost work productivity, and detail QOL and social impacts of the condition.

Association between adherence to continuous positive airway pressure treatment and cost among medicare enrollees.

OBJECTIVE: To analyze the cost associated with sleep apnea and effects of continuous positive airway pressure (CPAP) treatment on costs among fee-for-service Medicare beneficiaries. METHODS: Retrospective cohort design using 5% Medicare claims between 2006 and 2010. Medicare beneficiaries with and without sleep apnea diagnosis between 2007 and 2008 were identified and followed retrospectively for 2 years pre-index-date and 2 years post-index-date. We defined CPAP fill as at least one durable medical equipment claim for CPAP in 6-month period. At least three CPAP fills was defined as "full adherence," and one or two CPAP fills was "partial adherence." We used interrupted time series and generalized linear log-link models to study the association between sleep apnea, CPAP treatment, and costs. To minimize bias, we used propensity score and instrumental variables approach. RESULTS: Sleep apnea was associated with higher costs (odds ratio [OR] = 1.60; 95% confidence interval [CI] = 1.58, 1.63) compared to those without sleep apnea. Almost half of those with sleep apnea received CPAP treatment. Interrupted time series analysis indicated post level increase in mean monthly cost for full CPAP adherence group, partial CPAP adherence group and no-CPAP group. However, the increase was smallest for the full CPAP adherence group. Full CPAP adherence was associated with lower change in cost (OR = 0.92; 95% CI = 0.88, 0.97) compared to the no-CPAP group. CONCLUSIONS: Medicare beneficiaries with sleep apnea experience increased cost. Full adherence to CPAP treatment for sleep apnea was associated with lower increase in cost. These findings emphasize the need to effectively identify and treat sleep apnea in Medicare patients.

Reducing preterm mortality in eastern Uganda: the impact of introducing low-cost bubble CPAP on neonates <1500 g.

BACKGROUND: Complications of prematurity are the leading cause of deaths in children under the age of five. The predominant reason for these preterm deaths is respiratory distress syndrome (RDS). In low-income countries (LICs) there are limited treatment options for RDS. Due to their simplicity and affordability, low-cost bubble continuous positive airway pressure (bCPAP) devices have been introduced in neonatal units in LICs to treat RDS. This study is the first observational study from a LIC to compare outcomes of very-low-birth-weight (VLBW) neonates in pre- and post-CPAP periods. METHODS: This was a retrospective study of VLBW neonates (weight < 1500 g) in Mbale Regional Referral Hospital Neonatal Unit (MRRH-NNU), a government hospital in eastern Uganda. It aimed to measure the outcome of VLBW neonates in two distinct study periods: A 14-month period beginning at the opening of MRRH-NNU and covering the period until bCPAP was introduced (pre-bCPAP) and an 18-month period following the introduction of bCPAP (post-bCPAP). After the introduction of bCPAP, it was applied to preterm neonates with RDS when clinically indicated and if a device was available. Clinical features and outcomes of all neonates < 1500 g were compared before and after the introduction of bCPAP. RESULTS: The admission records of 377 VLBW neonates < 1500 g were obtained. One hundred fifty-eight were admitted in the pre-bCPAP period and 219 in the post-bCPAP period. The mortality rate in the pre- bCPAP period was 39.2% (62/158) compared with 26.5% (58/219, P = 0.012) in the post-bCPAP period. Overall, there was a 44% reduction in mortality (OR 0.56, 95%CI 0.36-0.86, P = 0.01). There were no differences in birthweight, sex, presence of signs of respiratory distress or apnoea between the two groups. CONCLUSION: Specialized and resource-appropriate neonatal care, that appropriately addresses the challenges of healthcare provision in LICs, has the potential to reduce neonatal deaths. The use of a low-cost bCPAP to treat RDS in VLBW neonates resulted in a significant improvement in their survival in a neonatal unit in eastern Uganda. Since RDS is one of the leading causes of neonatal mortality, it is possible that this relatively simple and affordable intervention could have a huge impact on global neonatal mortality.

A Cost-Effective Novel Innovative Box (C-Box) to Prevent Cockroach Infestation of Continuous Positive Airway Pressure Equipment: A Unique Problem in Northern Tropical Australia.

Cockroaches and other pests infestation of continuous positive airway pressure (CPAP) equipment has been rarely reported in the medical literature. In this report, we describe a box (C-Box) designed to prevent pest infestation of the CPAP equipment. Over experience, using this C-Box has demonstrated that it can prevent pest infestation and reduce the cost of replacing pest-infested CPAP machines.

A new low-cost commercial bubble CPAP (bCPAP) machine compared with a traditional bCPAP device in Nigeria.

Background: The bubble continuous positive airway pressure (bCPAP) technique is widely applied in neonatal respiratory support. Commercial bCPAP brands are expensive in Nigeria and this has driven Nigerian paediatricians to use potentially risky improvised devices (IbCPAP). Aim: This study aimed to design, produce and trial an appropriate low-cost bCPAP machine which is functionally effective and safe. Methods: Questionnaires were distributed to assess the need for a new bCPAP design for use in Nigeria, leading to the development of a new system (politeCPAP) which was functionally and clinically validated in three Nigerian hospitals. Six months of clinical data on the new device of sufficient comparative quality were generated from one of the hospitals and compared with control data on the IbCPAP. The hospitals (n = 3) submitted data on 71 patients on IbCPAP or politeCPAP; 14 were disqualified on the basis of the elimination criteria. The infants were classified into two birthweight categories: <1000 g (extremely low birthweight, ELBW, n = 15) and 1000 g (n = 42). Results: Six ELBW neonates on politeCPAP survived; there were no ELBW survivors in the IbCPAP group (n = 9). The IbCPAP device delivered an average 90% O2-gas ratio (FiO2) whereas the politeCPAP required only 47%. Many heavier neonates in the IbCPAP group survived (23 of 26); however, supplementary warming was required for all of them whereas none of the politeCPAP infants required warming. The politeCPAP costs around US$2000 whereas standard commercial CPAP brands in Nigeria range from US$5000 to US$18,000. High oxygen requirement and iatrogenic hypothermia were serious adverse features of IbCPAP. Conclusions: The study has narrowed the gap between relatively low-cost, risky devices (e.g. IbCPAP) and high-cost commercial machines. The politeCPAP is a feasible alternative to the IbCPAP in cost-constrained settings. Abbreviations: bCPAP: bubble continuous positive airway pressure; CPAP: continuous positive airway pressure; ELBW: extremely low birthweight; FiO2: ratio of oxygen content in gas flow (%); IbCPAP: improvised bubble continuous positive airway pressure device; LBW: low birthweight; NNU: neonatal unit; PEEP: positive end expiratory pressure; politeCPAP: the newly developed commercial bCPAP machine; RDS: respiratory distress syndrome; SpO2, oxygen saturation level (%).

System for Monitoring User Engagement with Personalized Medical Devices to Improve Use and Health Outcomes.

Medical devices used in a home setting for treating a variety of chronic diseases lack the ability to convey meaningful information to the patients directly about how they are engaging with their devices in real-time. This research is focused on the development of a monitoring system that addresses this need. For this initial design and testing, the research team applied the technology to a positive airway pressure (PAP) system used in the treatment of those suffering from obstructive sleep apnea (OSA). Data from experimental testing showed results of 93.6% accuracy, 98.7% sensitivity, and 90.9% specificity in the monitoring system detecting events that are typical of issues occurring during standard PAP therapy use. Results indicate this technology can be considered as a viable solution for providing more meaningful information to users about their engagement with their prescribed medical devices.

Assessment of resistance of nasal continuous positive airway pressure interfaces.

OBJECTIVE: To compare the resistance of interfaces used for the delivery of nasal continuous positive airway pressure (CPAP) in neonates, as measured by the generated system pressure at fixed gas flows, in an in vitro setting. DESIGN: Gas flows of 6, 8 and 10 L/min were passed through three sizes of each of a selection of available neonatal nasal CPAP interfaces (Hudson prong, RAM Cannula, Fisher & Paykel prong, Infant Flow prong, Fisher & Paykel mask, Infant Flow mask). The expiratory limb was occluded and pressure differential measured using a calibrated pressure transducer. RESULTS: Variation in resistance, assessed by mean pressure differential, was seen between CPAP interfaces. Binasal prong interfaces typically had greater resistance at the smallest assessed sizes, and with higher gas flows. However, Infant Flow prongs produced low pressures (<1.5 cmH2O) at all sizes and gas flows. RAM Cannula had a high resistance, producing a pressure >4.5 cmH2O at all sizes and gas flows. Both nasal mask interfaces had low resistance at all assessed sizes and gas flows, with recorded pressure <1 cmH2O in all cases. CONCLUSIONS: There is considerable variation in measured resistance of available CPAP interfaces at gas flows commonly applied in clinical neonatal care. Use of interfaces with high resistance may result in a greater drop in delivered airway pressure in comparison to set circuit pressure, which may have implications for clinical efficacy. Device manufacturers and clinicians should consider CPAP interface resistance prior to introduction into routine clinical care.

Risk and benefits of Bubble Continuous Positive Airway Pressure for neonatal and childhood respiratory diseases in Low- and Middle-Income countries.

Over 80% of the global burden of childhood deaths occur in Low- and Middle-Income Countries (LMIC). Of the leading causes of death, respiratory failure is common to the top three. Bubble Continuous Positive Airway Pressure (bCPAP) is a standard therapy considered safe and cost effective in high resource settings. Although high-quality trials from LMIC are few, pooled available trial data considered alongside studies from high-income countries suggest that bCPAP: (i) reduces mortality; (ii) reduces the need for mechanical ventilation; and (iii) prevents extubation failure. Wider availability and optimal use at all levels of the health care system in LMIC are important steps to improve childhood survival. Studies aimed at effectively implementing, and sustaining safe use of bCPAP in the resource limited setting of LMIC are required.

Efficacy and safety assessment of expiratory positive airway pressure (EPAP) mask for OSAHS therapy.

OBJECTIVE: We have designed the expiratory positive airway pressure (EPAP) mask to provide a new sort of therapeutic strategies for Obstructive Sleep Apnea Hypopnea Syndrome (OSAHS). And this study aims to assess the safety, efficacy and compliance of the EPAP therapy. METHODS: 40 healthy volunteers were enrolled to measure the end-tidal carbon dioxide pressure (PETCO2) while being treated by EPAP mask. 40 symptomatic moderate or severe OSAHS patients (AHI≥15/h) recruited were equally divided into two groups randomly and treated with CPAP or mask for a week respectively. After a week of washing out, the patients were applied with exchanged therapeutic methods for another week. The PSG was performed at the end of each week of treatment with device-on. RESULTS: There were no significant differences of PETCO2 under different exhaled positive pressure level between CPAP, EPAP therapies and non-therapy for the healthy volunteers (P>0.05). After being treated, among the OSAHS patients in the two groups, the ESS scores and AHI decreased, and minimum SaO2 and mean SaO2 increased significantly (all P>0.05). There was no significant differences of the efficacy between EPAP and CPAP therapy. CONCLUSIONS: EPAP mask therapy was safe and reliable with significant efficacy for selected OSAHS patients. However, the compliance needs further improvement.