Nasal versus full face mask for noninvasive ventilation in chronic respiratory failure.

This study was undertaken to determine the efficacy of nasal mask (NM) versus full face mask (FFM) for the delivery of noninvasive ventilation (NIV) in subjects with nocturnal hypoventilation. A total of 16 patients (11 males) were enrolled, all with nocturnal hypoventilation currently treated at home with NIV via pressure preset devices. Subjects underwent full polysomnography on three occasions; on the first night current therapy on NM was reviewed, followed by two experimental studies in randomised order using either NM or FFM. NIV settings and oxygen flow rate were the same under both conditions. Notably, 14 of the 16 subjects required the use of a chinstrap to minimise oral leak. Apnoea-hypopnoea indices were within normal limits under both conditions (1.7 +/- 3.4 NM versus 1.6 +/- 2.4 h FFM). The type of interface did not significantly affect gas exchange during sleep (minimum average arterial oxyhaemoglobin saturation total sleep time 93.4 +/- 2.1 NM versus 92.8 +/- 2.5% FFM, Delta transcutaneous carbon dioxide nonrapid eye movement sleep to rapid eye movement sleep (0.58 +/- 0.36 NM versus 0.50 +/- 0.40 kPa FFM). Sleep efficiency was significantly reduced on the FFM (78 +/- 9 NM versus 70 +/- 14% FFM), although arousal indices were comparable under both conditions (15.6 +/- 9.8 NM versus 15.8 +/- 8.8 h FFM). Full face masks appear to be as effective as nasal masks in the delivery of noninvasive ventilation to patients with nocturnal hypoventilation. However, a chinstrap was required to reduce oral leak in the majority of subjects using the nasal mask.

Predicting sleep-disordered breathing in patients with cystic fibrosis.

STUDY OBJECTIVES: To examine predictors of sleep-disordered breathing in patients with cystic fibrosis (CF) and moderate-to-severe lung disease using a comprehensive evaluation of both sleep and daytime function. DESIGN: Cross-sectional analysis of sleep studies, lung function, respiratory muscle strength, and evening and morning arterial blood gas measurements in patients with stable CF. A questionnaire addressing sleep quality was administered. Forward stepwise regression analysis was used to identify the parameters that best predict sleep-related desaturation, hypercapnia, and respiratory disturbance. SETTING: Sleep investigation unit and lung function laboratory. PATIENTS: Thirty-two patients with CF and FEV(1) < 65% predicted, in stable clinical condition. Patients were aged 27 +/- 8 years (mean +/- 1 SD) with FEV(1) of 36 +/- 10% predicted, evening PaO(2) of 68 +/- 8 mm Hg, and PaCO(2) of 43 +/- 5 mm Hg. RESULTS: Evening PaO(2) (p < 0.0001) and morning PaCO(2) (p < 0.01) were predictive of the average minimum oxyhemoglobin saturation per 30-s epoch of sleep (r(2) = 0.74; p < 0.0001). Evening PaO(2) (p < 0.001) was predictive of the rise in transcutaneous carbon dioxide (TcCO(2)) seen from non-rapid eye movement (NREM) to rapid eye movement (REM) sleep (r(2) = 0.37; p < 0.001). In addition, there was some relationship between expiratory respiratory muscle strength and the REM respiratory disturbance index (r(2) = 0.22; p < 0.01). CONCLUSION: Evening PaO(2) was found to contribute significantly to the ability to predict both sleep-related desaturation and the rise in TcCO(2) from NREM sleep to REM sleep in this subgroup of patients with CF.

Noninvasive pressure preset ventilation for the treatment of Cheyne-Stokes respiration during sleep.

Cheyne-Stokes respiration (CSR) during sleep is common in patients with congestive heart failure (CHF). This pattern of breathing fragments sleep, leading to daytime symptoms of sleepiness and fatigue. It was hypothesized that by controlling CSR with noninvasive pressure preset ventilation (NPPV), there would be a decrease in sleep fragmentation and an improvement in sleep quality. Nine patients (eight males, one female; mean +/- SD 65 +/- 11 yrs) with symptomatic CSR diagnosed on overnight polysomnography (apnoea/hypopnoea index (AHI) 49 +/- 10 x h(-1), minimum arterial oxygen saturation (Sa,O2, 77 +/- 7%) and CHF (left ventricular ejection fraction 25 +/- 8%) were studied. After a period of acclimatization to NPPV (variable positive airway pressure (VPAP) II ST, Sydney, NSW, Australia and bilevel positive airway pressure (BiPAP), Murraysville, PA, USA), sleep studies were repeated on therapy. NPPV almost completely abolished CSR in all patients with a reduction in AHI from 49 +/- 10 to 6 +/- 5 x h(-1) (p<0.001). Residual respiratory events were primarily due to upper airway obstruction at sleep on-set. Arousal index was markedly decreased from 42 +/- 6 to 17 +/- 7 x h(-1) (p <0.001). Sleep architecture showed a trend toward improvement with a reduction in stage 1 and 2 (79 +/- 7% during the diagnostic night versus 72 +/- 10% during NPPV, (p=0.057)), whilst sleep efficiency, slow-wave sleep (SWS), and rapid eye movement (REM) were not altered. Controlling Cheyne-Stokes respiration with noninvasive pressure preset ventilation resulted in reduced arousal and improved sleep quality in the patients with congestive heart failure. Noninvasive pressure preset ventilation should be considered a potential therapy for Cheyne-Stokes respiration in congestive heart failure in those patients who do not respond or fail to tolerate nasal continuous positive airway pressure therapy.

Low-flow oxygen and bilevel ventilatory support: effects on ventilation during sleep in cystic fibrosis.

We measured ventilation in all sleep stages in patients with cystic fibrosis (CF) and moderate to severe lung disease, and compared the effects of low-flow oxygen (LFO2) and bilevel ventilatory support (BVS) on ventilation and gas exchange during sleep. Thirteen subjects, age 26 +/- 5.9 yr (mean +/- 1 SD), body mass index (BMI) 20 +/- 3 kg/m2, FEV1 32 +/- 11% predicted, underwent three sleep studies breathing, in random order, room air (RA), LFO2, and BVS +/- O2 with recording of oxyhemoglobin saturation (SpO2) (%) and transcutaneous carbon dioxide (TcCO2) (mm Hg). During RA and LFO2 studies, patients wore a nasal mask with a baseline continuous positive airway pressure (CPAP) of 4 to 5 cm H2O. Minute ventilation (V I) was measured using a pneumotachograph in the circuit and was not different between wake and non-rapid eye movement (NREM) sleep on any night. However, V I was reduced on the RA and LFO2 nights from awake to rapid eye movement (REM) (p < 0.01) and from NREM to REM (p < 0.01). On the BVS night there was no significant difference in V I between NREM and REM sleep. Both BVS and LFO2 improved nocturnal SpO2, especially during REM sleep (p < 0.05). The rise in TcCO2 seen with REM sleep with both RA and LFO2 was attenuated with BVS (p < 0.05). We conclude that BVS leads to improvements in alveolar ventilation during sleep in this patient group.

Asymmetrical noise exposure and hearing loss among shingle sawyers.

Shingle sawyers are exposed to noise predominantly from the left side. This study examined the asymmetry in hearing loss among shingle sawyers and its possible relation to the difference in noise exposure to the two ears. The results suggest that the lateral difference in noise exposure in industry, even in the obvious case of a shingle sawyer, is small. The resulting asymmetrical noise-induced hearing loss is also relatively small. Therefore, significant asymmetry in hearing loss in this type of occupation should be viewed with caution. Special tests and medical examination should be undertaken to determine if there are other contributing factors.

The ear effect as a function of age and hearing loss.

Many studies have shown that the right ear statistically is slightly more sensitive than the left ear, particularly in the male adult population. In this study, we examined the lateral difference in hearing sensitivity, termed the ear effect here, in an industrial noise-exposed, nonshooting population, by sex, age, and hearing level. It was found that the male population had a larger ear effect (right ear being more sensitive) than the female population. The magnitude of the ear effect was found to be significantly related to the hearing threshold level. The ear effect was highest when the threshold was between 30- and 40-dB HL. Several possible causes for the ear effect are discussed.

Lateral differences in susceptibility to noise damage.

Usually equal noise exposure is considered to cause symmetrical hearing loss. In studying 1 461 audiometric records of claims for noise-induced hearing loss, it was found that 69 (4.7%) had a well-defined pattern of hearing loss in which only 2 kHz is asymmetrical by 20 dB or more. Audiograms of this type suggest that the cochlea of the worse ear has been damaged more extensively towards the apex. Of the 69 cases with a 2-kHz asymmetry, 82.6% had worse hearing thresholds in the left ear at 2 kHz. In 50% of the 69 cases, the asymmetry could not be accounted for even after the examination of their medical, occupational and nonoccupational histories. It is believed that the asymmetry at 2 kHz is a manifestation of a lateral difference in susceptibility to noise damage and that the left ear is the more susceptible one in the majority of cases.

Shooting, sensorineural hearing loss, and workers' compensation.

Pure-tone audiograms of 29,953 workers with histories of shooting and occupational noise exposure were analyzed. The analysis was based on the asymmetry of hearing loss. Results of this study show that shooting is related to asymmetrical hearing loss, suggesting that shooting may cause an additional amount of hearing loss other than that due to occupational noise exposure. Asymmetry was found to increase as the length of shooting history increased and was significant only at 2 kHz and above and most prominent at 4 kHz. Results also indicated that as long as compensable frequencies remain below 3 kHz the shooting effect is not likely to influence compensation for workers with histories of less than ten years of shooting.

Is a healthier person less susceptible to noise-induced hearing loss?

Several studies in the literature suggest that poor health is related to hearing loss. One hundred subjects claiming occupational hearing loss were chosen randomly for this study. Information was obtained on employment, noise exposure, medical history, family history, and use of cigarettes, alcohol, and medication. Physical examination audiometric tests, and biological tests were carried out. Computer analysis of the data with chi-square test did not show conclusively that noise-induced hearing loss is related to poor health, indicated by abnormal biological or physical findings, or both. There were, however, some indications that the presence of cardiovascular risk factors may influence hearing loss.

Auditory and vestibular damage in head injuries at work.

A series of 50 unselected patients who reported a head injury to the Workers' Compensation Board of British Columbia were referred to the AudioVestibular Unit of the Vancouver General Hospital for studies of auditory and vestibular function. All patients were interviewed and examined by a neuro-otology team during the course of their investigation. It was found that dizziness was the most common symptom of which they complained (60%), and bleeding from the ear was the least common (4%). Of the 50 patients studied, 32% showed evidence of either auditory and/or vestibular injury. Of the total number studied, 16% had auditory injuries and 26% had vestibular injuries. The most common auditory injury was unilateral partial loss of hearing. Central vestibular dysfunction was the most common vestibular injury. A study of the most effective means of selecting patients from the population with head injuries for referral for audiology and vestibular testing was undertaken. The most effective combination of symptoms for referral is the presence of one or more of the triad: hearing loss, unsteadiness, or loss of consciousness/amnesia.