Automatic EPAP intelligent volume-assured pressure support is effective in patients with chronic respiratory failure: A randomized trial.

BACKGROUND AND OBJECTIVE: Patients with chronic respiratory failure are increasingly managed with domiciliary non-invasive ventilation (NIV). There may be limited ability to provide NIV titration for these complex patients, and ventilatory requirements and upper airway support needs may change over time. Therefore, an automatically adjusting expiratory positive airway pressure (AutoEPAP) algorithm may offer advantages over manually adjusted EPAP for treating these patients. This study compared 4% oxygen desaturation index (ODI4%) values during the use of an AutoEPAP algorithm versus manual EPAP titration with the intelligent volume-assured pressure support (iVAPS) algorithm. METHODS: This prospective, single-blind, randomized, crossover study was conducted at six US sites. Patients with chronic respiratory failure (neuromuscular disease, chronic obstructive pulmonary disease, obesity hypoventilation and other aetiologies) and an apnoea-hypopnoea index of >5/h who were already established NIV users underwent a single night of NIV with the iVAPS manual EPAP and iVAPS AutoEPAP in the sleep laboratory in random order. RESULTS: A total of 38 patients constituted the study population. Mean ODI4% was statistically non-inferior with AutoEPAP versus manual EPAP (P < 0.0001). There was no difference in the effect on ODI4% across respiratory failure subgroups. Ventilation parameters and gas exchange were similar with either NIV mode, indicating equally effective treatment of respiratory failure. Sleep parameters were improved during AutoEPAP versus manual EPAP. CONCLUSION: A single night of NIV using the iVAPS with AutoEPAP algorithm was non-inferior to a single night of iVAPS with manual EPAP titration in patients with respiratory failure. CLINICAL TRIAL REGISTRATION: NCT02683772 at clinicaltrials.gov.

Polysomnographic characteristics of adolescents with asthma and low risk for sleep-disordered breathing.

PURPOSE: The aim of this study was to describe the polysomnographic characteristics of adolescents with asthma who are at low risk for sleep-disordered breathing (SDB) based on the Pediatric Sleep Questionnaire (PSQ). METHODS: Overnight polysomnography was performed on 85 adolescents with asthma and a score < 0.33 on the PSQ. The Asthma Control Questionnaire was used to define "well-controlled" versus "inadequately controlled" asthma. RESULTS: Mean age of participants was 14.5 ± 1.6 years (range, 11 to 17 years), 63.5% were girls, 57.6% were Caucasians, and the mean body mass index percentile was 65.1 ± 26.5. Asthma was well-controlled in 51.7% of the adolescents and inadequately controlled in 15.3%. Mean sleep efficiency (SE) was 88.0 ± 11.1%, and 24.7% had SE < 85%. Mean wakefulness after sleep onset (WASO) was 40.9 ± 44.0 min, and the mean arousal index was 10.8 ± 5.6 per hour. The mean apnea/hypopnea index (AHI) was 2.3 ± 4.2, and 29.4% of participants had SDB (defined by an AHI ≥ 2). Compared with normative values, adolescents with asthma had more nocturnal awakenings and WASO, and less REM sleep. SDB risk was higher in boys [odds ratio = 4.6 (confidence interval 1.4-14.7), p = 0.01]. Asthma control did not impact sleep and respiratory parameters, with no differences found between youth with well-controlled and inadequately controlled asthma. CONCLUSIONS: Adolescents with asthma are at increased risk of sleep-disordered breathing and suffer from disturbances in sleep continuity with more arousals and sleep fragmentation. Study results highlight the importance of proper screening for sleep-disordered breathing in adolescents with asthma.

Neurocognitive performance in insomnia disorder: The impact of hyperarousal and short sleep duration.

Given the recent evidence on the association between hyperarousal in insomnia disorder and neurocognitive deficits, we aimed to examine the effect of short sleep duration on neurocognitive reaction time tests in insomnia disorder sufferers. We recruited subjects with insomnia disorder (n = 35, mean age = 40.6 years) who scored ≥29 on a Hyperarousal Scale, and a group of controls (n = 54, mean age = 31.5 years) who had no sleep disorders and scored <26 on the Hyperarousal Scale. Participants completed two in-home polysomnograms and four daytime trials of neurocognitive tests, including simple reaction time, choice reaction time, big circle-little circle, rapid visual information processing, attention switching task, and spatial working memory tests. Total sleep time divided study cohorts into subgroups of short (total sleep time <6 hr) and normal (total sleep time ≥6 hr) sleepers. ANCOVA showed a significant interaction between participant type (insomnia disorder versus controls) and sleep duration (short versus normal) for spatial working memory-latency (p = 0.020) and spatial working memory-errors (p = 0.025). The short-sleeping insomnia disorder group had longer spatial working memory-latencies and more spatial working memory-errors than did normal-sleeping controls. Regardless of sleep duration, those with insomnia disorder had more attentional deficits with longer attention switching task-latency (p = 0.011) and more attention switching task-incorrect trials (p = 0.015) than the control group. Normal-sleepers only had longer attention switching task-latency than short-sleepers (p = 0.004). A phenotype of insomnia disorder with hyperarousal and short sleep duration is associated with daytime cognitive deficits in complex attentional and spatial working memory tasks.

Chronic obstructive pulmonary disease and sleep related disorders.

PURPOSE OF REVIEW: Sleep related disorders are common and under-recognized in the chronic obstructive pulmonary disease (COPD) population. COPD symptoms can disrupt sleep. Similarly, sleep disorders can affect COPD. This review highlights the common sleep disorders seen in COPD patients, their impact, and potential management. RECENT FINDINGS: Treatment of sleep disorders may improve quality of life in COPD patients. Optimizing inhaler therapy improves sleep quality. Increased inflammatory markers are noted in patients with the overlap syndrome of COPD and obstructive sleep apnea versus COPD alone. There are potential benefits of noninvasive positive pressure ventilation therapy for overlap syndrome patients with hypercapnia. Nocturnal supplemental oxygen may be beneficial in certain COPD subtypes. Nonbenzodiazepine hypnotic therapy for insomnia has shown benefit without associated respiratory failure or worsening respiratory symptoms. Melatonin may provide mild hypnotic and antioxidant benefits. SUMMARY: This article discusses the impact of sleep disorders on COPD patients and the potential benefits of managing sleep disorders on respiratory disease control and quality of life.

Sleep and the Endocrine System.

In this article, the effect of sleep and sleep disorders on endocrine function and the influence of endocrine abnormalities on sleep are discussed. Sleep disruption and its associated endocrine consequences in the critically ill patient are also reviewed.

Managing Comorbid Illness in Obstructive Sleep Apnea: What Can We Learn from Other Diseases?

Obstructive sleep apnea (OSA) is associated with numerous comorbid medical conditions. Symptoms of OSA may mimic those of comorbid conditions. The presence of OSA may worsen outcomes from the primary condition. Conversely, OSA treatment may benefit both sleep symptomatology and comorbid illness. Because of potential significant benefit, it is important to screen for sleep apnea symptoms, to have a low threshold to perform diagnostic testing, to treat OSA if present, and to closely monitor symptoms. OSA management does not necessarily replace, but rather, should be performed in conjunction with primary therapy for comorbid conditions.

Sleep and the endocrine system.

In this article, the effect of sleep and sleep disorders on endocrine function and the influence of endocrine abnormalities on sleep are discussed. Sleep disruption and its associated endocrine consequences in the critically ill patient are also reviewed.

Detection of upper airway status and respiratory events by a current generation positive airway pressure device.

STUDY OBJECTIVES: To compare a positive airway pressure (PAP) device's detection of respiratory events and airway status during device-detected apneas with events scored on simultaneous polysomnography (PSG). DESIGN: Prospective PSGs of patients with sleep apnea using a new-generation PAP device. SETTINGS: Four clinical and academic sleep centers. PATIENTS: Forty-five patients with obstructive sleep apnea (OSA) and complex sleep apnea (Comp SA) performed a PSG on PAP levels adjusted to induce respiratory events. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: PAP device data identifying the type of respiratory event and whether the airway during a device-detected apnea was open or obstructed were compared to time-synced, manually scored respiratory events on simultaneous PSG recording. Intraclass correlation coefficients between device-detected and PSG scored events were 0.854 for apnea-hypopnea index (AHI), 0.783 for apnea index, 0.252 for hypopnea index, and 0.098 for respiratory event-related arousals index. At a device AHI (AHIFlow) of 10 events/h, area under the receiver operating characteristic curve was 0.98, with sensitivity 0.92 and specificity 0.84. AHIFlow tended to overestimate AHI on PSG at values less than 10 events/h. The device detected that the airway was obstructed in 87.4% of manually scored obstructive apneas. Of the device-detected apneas with clear airway, a minority (15.8%) were manually scored as obstructive apneas. CONCLUSIONS: A device-detected apnea-hypopnea index (AHIFlow) < 10 events/h on a positive airway pressure device is strong evidence of good treatment efficacy. Device-detected airway status agrees closely with the presumed airway status during polysomnography scored events, but should not be equated with a specific type of respiratory event.

Excessive sleepiness.

Sleepiness is a commonly experienced symptom affecting up to one-fifth of the population chronically. Sleepiness contributes to systemic health effects, and has been shown to contribute to mood disorders and cardiovascular risks. Sleepiness also presents a significant public health risk: it has been associated with major catastrophes, motor vehicle accidents, and medical errors by health care workers. This article reviews the implications of sleepiness on public health, the evaluation of sleepiness, disorders that result in sleepiness, and the management of these disorders.