Poor sleep quality is associated with late noninvasive ventilation failure in patients with acute hypercapnic respiratory failure*

Abstract

To determine whether sleep quality helps to predict noninvasive ventilation outcome in patients with acute hypercapnic respiratory failure. Despite an initial clinical improvement, nearly one fourth of patients may fail noninvasive ventilation after several days. Because late intubation is associated with a poor prognosis, it may be useful to identify factors that may predict or explain late noninvasive ventilation failure. We prospectively studied 27 hypercapnic patients in a medical intensive care unit who required noninvasive ventilation for >48 hrs. A 17-hr sleep polysomnography (3 PM-8 AM) was recorded 2 days to 4 days after noninvasive ventilation initiation. Late noninvasive ventilation failure was defined as death, endotracheal intubation, or persistent need for noninvasive ventilation on day 6. An abnormal electroencephalographic pattern that eluded analysis by standard sleep-scoring criteria was noted in seven (50%) of the 14 patients with late noninvasive ventilation failure compared with one (8%) of the 13 patients successfully treated with noninvasive ventilation (p = .03). No clinical or laboratory variables explained the electroencephalographic differences. Patients failing noninvasive ventilation had poorer sleep quality with greater circadian sleep-cycle disruption and less nocturnal rapid eye movement sleep (6 mins [range, 0-12] vs. 26 mins [range, 6-49], p = .03), compared with patients successfully treated with noninvasive ventilation. Noninvasive ventilation failure was associated with delirium during the intensive care unit stay (64% vs. 0%). Late noninvasive ventilation failure in elderly patients with acute hypercapnic respiratory failure was associated with early sleep disturbances including an abnormal electroencephalographic pattern, disruption of the circadian sleep cycle, and decreased rapid eye movement sleep.