Continuous Positive Airway Pressure Pressure Research Articles

Association Between Obstructive Sleep Apnea (OSA) Severity and Optimal Continuous Positive Airway Pressure (CPAP); Do Severe OSA Patients Always Need High CPAP Pressure?

Objective: Obstructive sleep apnea (OSA) is a prevalent sleep disorder associated with an increased risk of cardiovascular disease. Severity of OSA is assessed using the apnea-hypopnea index (AHI), but the optimal continuous positive airway pressure (CPAP) does not always correlate proportionally with AHI. This study aims to identify factors leading to the need for high CPAP pressure despite low AHI or vice versa.Methods: The study includes 91 patients diagnosed with OSA through polysomnography. Participants undergoing CPAP titration were categorized in three groups based on AHI (30/h) and optimal CPAP pressure (10 cm H<sub>2</sub>O); low AHI and high CPAP pressure group (LH group), high AHI and low CPAP pressure group (HL group), direct proportion group (DP group). The Kruskal–Wallis nonparametric statistical test is used to identify significant differences between the three groups.Results: Among the subjects, 78% were male, with no significant age or BMI differences between groups. There were 36 (39.6%) subjects with mild to moderate OSA and 55 (60.4%) subjects with severe OSA. The study revealed that patients requiring high CPAP pressure despite low AHI (LH group) had lower AHI, oxygen desaturation index, and various other parameters compared to other groups as expected. However, certain factors like the percentage of hypopnea in AHI, limb movement (LM) arousal index, and spontaneous arousal index were higher in the LH group.Conclusion: Patients with mild to moderate OSA requiring high CPAP pressure are more likely associated with specific aspects such as hypopnea in AHI, LM arousal, and spontaneous arousal index, presenting unpredictable outcomes.

CPAP Versus NIPPV Postextubation in Preterm Neonates: A Comparative-Effectiveness Study.

Nasal intermittent positive pressure ventilation (NIPPV) has been shown to be superior to nasal continuous positive airway pressure (CPAP) postextubation in preterm neonates. However, studies have not permitted high CPAP pressures or rescue with other modes. We hypothesized that if CPAP pressures >8 cmH2O and rescue with other modes were permitted, CPAP would be noninferior to NIPPV. We conducted a pragmatic, comparative-effectiveness, noninferiority study utilizing network-based real-world data from 22 Canadian NICUs. Centers self-selected CPAP or NIPPV as their standard postextubation mode for preterm neonates <29 weeks' gestation. The primary outcome was failure of the initial mode ≤72 hours. Secondary outcomes included failure ≤7 days, and reintubation ≤72 hours and ≤7 days. Groups were compared using a noninferiority adjusted risk-difference (aRD) margin of 0.05, and margin of no difference. A total of 843 infants extubated to CPAP and 974 extubated to NIPPV were included. CPAP was not noninferior (and inferior) to NIPPV for failure of the initial mode ≤72 hours (33.0% vs 26.3%; aRD 0.07 [0.03 to 0.12], Pnoninferiority(NI) = .86), and ≤7 days (40.7% vs 35.8%; aRD 0.09 [0.05 to 0.13], PNI = 0.97). However, CPAP was noninferior (and equivalent) to NIPPV for reintubation ≤72 hours (13.2% vs 16.1%; aRD 0.01 [-0.05 to 0.02], PNI < .01), and noninferior (and superior) for reintubation ≤7 days (16.4% vs 22.8%; aRD -0.04 [-0.07 to -0.001], PNI < .01). CPAP was not noninferior to NIPPV for failure ≤72 hours postextubation; however, it was noninferior to NIPPV for reintubation ≤72 hours and ≤7 days. This suggests CPAP may be a reasonable initial postextubation mode if alternate rescue strategies are available.

Mask Continuous Positive Airway Pressure Increases Diaphragm Thickening Fraction in Healthy Subjects

Introduction: The most widespread treatment for obstructive sleep apnoea and obesity hypoventilation syndrome is continuous positive airway pressure (CPAP). The addition of inspiratory support is a potential alternative. This is a physiological study to determine the effect of CPAP and inspiratory support pressure on respiratory effort measured by diaphragm thickening fraction (DTF) in healthy volunteers. Methods: DTF was measured in spontaneously breathing, healthy volunteers during 4 phases: (I) without connection to a ventilator, (II) on a ventilator without any applied pressures, (III) with a CPAP of 5 cmH₂O, and (IV) with an additional inspiratory support pressure of 5 cmH₂O. Results: Twenty-nine individuals agreed to participate. DTF was similar during the first two phases (32 ± 13% and 35 ± 22%). A considerable increase in DTF to 51 ± 21% was noted in phase III. The introduction of inspiratory support pressure during phase IV led to a reduction in DTF back to 36 ± 23% (p < 0.001). Tidal volume and minute ventilation were both slightly higher in phase IV compared to phase III. Conclusion: CPAP without inspiratory support pressure increases respiratory effort measured by DTF in healthy subjects. Further research is required to investigate this phenomenon in a clinical setting.

An in-silico porcine model of phosgene-induced lung injury predicts clinically relevant benefits from application of continuous positive airway pressure up to 8 h post exposure

We present the first computational model of the pathophysiological consequences of phosgene-induced lung injury in porcine subjects. Data from experiments previously performed in several cohorts of large healthy juvenile female pigs (111 data points from 37 subjects), including individual arterial blood gas readings, respiratory rate and heart rate, were used to develop the computational model. Close matches are observed between model outputs (PaO2 and PaCO2) and the experimental data, for both terminally anaesthetised and conscious subjects. The model was applied to investigate the effectiveness of continuous positive airway pressure (CPAP) as a pre-hospital treatment method when treatment is initiated at different time points post exposure. The model predicts that clinically relevant benefits are obtained when 10 cmH2O CPAP is initiated within approximately 8 h after exposure. Supplying low-flow oxygen (40%) rather than medical air produced larger clinical benefits than applying higher CPAP pressure levels. This new model can be used as a tool for conducting investigations into ventilation strategies and pharmaceutical treatments for chemical lung injury of diverse aetiology, and for helping to refine and reduce the use of animals in future experimental studies.

Continuous Positive Airway Pressure plus Mandibular Advancement Therapy (PAPMAT): study protocol for an adaptive randomised crossover trial comparing the benefits and costs of combining two established treatments for obstructive sleep apnoea

BackgroundObstructive sleep apnoea (OSA) involves repeated breathing pauses during sleep due to upper airway obstruction. It causes excessive daytime sleepiness and has other health impacts. Continuous positive airway pressure (CPAP) therapy is effective first line treatment for moderate to severe OSA. Unfortunately, many patients have difficulty tolerating CPAP and pressure intolerance is probably an important contributing factor. Mandibular advancement devices (MAD) are an alternative to CPAP. They are worn in the mouth during sleep to reduce airway obstruction. There is some evidence that, when used in combination with CPAP, MADs improve airway anatomy enough to reduce the CPAP pressure required to treat OSA and that this combination therapy could improve CPAP adherence.MethodsConsecutive patients starting on CPAP for moderate to severe OSA will be recruited at a regional NHS sleep service. Patients with high CPAP pressure requirements after initial titration, who satisfy all entry criteria and consent to participate, will undertake a 2-arm randomised crossover trial. The arms will be (i) standalone CPAP and (ii) CPAP + MAD therapy. Each arm will last 12 weeks, including 2 weeks acclimatisation. CPAP machines will be auto-titrating and with facility for data download, so the impact of MAD on CPAP pressure requirements and CPAP adherence can be easily measured. The primary outcome will be CPAP adherence. Secondary outcomes will include measures of OSA severity, patient-reported outcome measures including subjective daytime sleepiness, quality of life, and treatment preference at the trial exit and health service use. Cost-effectiveness analyses will be undertaken.DiscussionIf the intervention is shown to be effective and cost-effective in improving adherence in this standard CPAP-eligible OSA patient population it would be relatively straightforward to introduce into existing OSA treatment pathways, within the wider NHS and more widely. Both MAD and CPAP are already used by sleep services so their combination would require only minor adjustments to existing clinical pathways. It would be straightforward to disseminate the results of the study through regional, national, and international respiratory meetings. The health economics analysis would provide cost-effectiveness data to inform service planning and clinical guidelines through policy briefing papers, including those by NICE and SIGN.Trial registrationPAPMAT was registered with ISRCTN prior to recruitment beginning (ISRCTN Registry 2021): https://www.isrctn.com/ISRCTN33966032. Registered on 17th November 2021.

Continuous positive airway pressure and adherence in patients with different endotypes of obstructive sleep apnea.

Determining the endotypes of obstructive sleep apnea (OSA) has potential implications for precision interventions. Here we assessed whether continuous positive airway pressure (CPAP) treatment outcomes differ across endotypic subgroups. We conducted a retrospective analysis of data obtained from 225 patients with moderate-to-severe OSA from a single sleep centre. Polysomnographic and CPAP titration study data were collected between May 2020 and January 2022. One-month CPAP treatment adherence was followed. Obstructive sleep apnea endotypes, namely arousal threshold, collapsibility, loop gain, and upper airway gain were estimated from polysomnography and dichotomised as high versus low. We examined associations between endotypic subgroups and (1) optimal CPAP titration pressure, (2) CPAP-related improvements in sleep architecture (proportions of slow-wave and rapid eye movement (REM) sleep), and (3) CPAP adherence. We observed that patients with high collapsibility required a higher CPAP pressure than those with low collapsibility (∆ = 0.4 cmH2 O, 95% confidence interval [CI] = 0.3-1.7). A larger increase in slow-wave sleep and in REM sleep proportions after CPAP treatment were observed in patients with a high arousal threshold, high collapsibility, high loop gain, or high upper airway gain than in those with low levels of endotypes. High loop gain and high collapsibility were independently associated with longer CPAP use hours per night (∆ = 0.6 h, 95% CI = 0.2-1.5 and ∆ = 0.3 h, 95% CI = 0.03-1.5, respectively). In conclusion, different endotypic subgroups of OSA exhibit a difference in outcomes of CPAP treatment. Knowledge of endotypes may help clinicians to understand which patients are expected to benefit most from CPAP therapy prior to its administration.

Risk factors of preterm infants with CPAP intubated for mechanical ventilation

Early use of continuous positive airway pressure (CPAP) is equal to the prophylactic administration of a surfactant to prevent neonatal respiratory distress syndrome (nRDS) in high-risk infants. However, almost half of the smallest infants still require intubation and mechanical ventilation in the first 72 hours after birth. It is known that ineffective initial CPAP is associated with a poorer prognosis. Therefore, the search for reliable prognostic risk factors for ineffective CPAP in very preterm neonates whose respiratory support is started with CPAP is still relevant today. The results of a retrospective cohort study conducted at the Lviv Regional Clinical Hospital (Ukraine), which included 151 children with birth weight &lt;1500 g and gestational age &lt;32 weeks, showed that CPAP failure occurred at a median age of five hours in 31% of infants initially treated with CPAP and average (SD) FiO2, while the failure point was 0.48 (0.15). The prevalence of the main risk factors for severe nRDS did not differ significantly between two groups (CPAP success and CPAP failure). The risk of CPAP failure was significantly associated with surfactant treatment (OR – 7.46; 95% CI: 2.3–24.2), severe RDS (OR – 12.17; 95% CI: 3.8–39.3), requirement in resuscitation after birth (OR – 3.10; 95% CI: 1.2–8.1), initial CPAP pressure (OR – 0.38; 95% CI: 0.15–0.99). Earlier administration of exogenous surfactant to children at high risk of developing severe RDS could prevent the need for mechanical ventilation. Keywords: CPAP failure, neonatal respiratory distress syndrome mechanical ventilation, preterm infants, surfactant

Encouraging Continuous Positive Airway Pressure Adherence With Personalized Strategies

Objectives: This study aimed to elucidate whether a comprehensive intervention focusing on individual characteristics could enhance adherence to Continuous Positive Airway Pressure (CPAP) in patients with Obstructive Sleep Apnea (OSA).Methods: We conducted a single-arm, pilot intervention study, recruiting participants aged ≥20 years with suspected OSA. All participants underwent split-night polysomnography and received standardized CPAP treatment. We identified five categories of factors contributing to poor CPAP adherence: mouth breathing, high CPAP pressure causing sleep initiation difficulties, bradypnea or hyperpnea before sleep onset, postarousal central apnea, and nasal dryness and obstruction. We objectively measured CPAP adherence data at 1, 3, 6 and 12 months after a comprehensive intervention targeting individual characteristics. We analyzed the trends in CPAP adherence rates over 1 year.Results: A total of 48 participants (74.0% males; 56.9±13.9 years old) were followed up for 12 months. CPAP adherence rate was 77.1% at 1 month; declined to 60.4%, 39.6%, and 31.3% at 3, 6, and 12 months, respectively. There was no significant difference in demographic and psychological factors, sleep-related symptoms, and sleep characteristics between the adherence and the non-adherence groups. Low body mass index was an independent risk factor affecting CPAP adherence (odds ratios 0.78, &lt;i&gt;p&lt;/i&gt;=0.04).Conclusions: Although our study did not yield significant improvements in CPAP adherence through the comprehensive intervention that targeted individual characteristics, it is significant because it attempted to provide a multidimensional approach to intervention, rather than targeting a single aspect, in promoting CPAP adherence.

Bubble devices versus other pressure sources for nasal continuous positive airway pressure in preterm infants.

Several types of pressure sources, including underwater bubble devices, mechanical ventilators, and the Infant Flow Driver, are used for providing continuous positive airway pressure (CPAP) to preterm infants with respiratory distress. It is unclear whether the use of bubble CPAP versus other pressure sources is associated with lower rates of CPAP treatment failure, or mortality and other morbidity. OBJECTIVES: To assess the benefits and harms of bubble CPAP versus other pressure sources (mechanical ventilators or Infant Flow Driver) for reducing treatment failure and associated morbidity and mortality in newborn preterm infants with or at risk of respiratory distress. We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2023, Issue 1); MEDLINE (1946 to 6 January 2023), Embase (1974 to 6 January 2023), Maternity & Infant Care Database (1971 to 6 January 2023), and the Cumulative Index to Nursing and Allied Health Literature (1982 to 6 January 2023). We searched clinical trials databases and the reference lists of retrieved articles. We included randomised controlled trials comparing bubble CPAP with other pressure sources (mechanical ventilators or Infant Flow Driver) for the delivery of nasal CPAP to preterm infants. We used standard Cochrane methods. Two review authors separately evaluated trial quality, extracted data, and synthesised effect estimates using risk ratio (RR), risk difference (RD), and mean difference. We used the GRADE approach to assess the certainty of the evidence for effects on treatment failure, all-cause mortality, neurodevelopmental impairment, pneumothorax, moderate-severe nasal trauma, and bronchopulmonary dysplasia. We included 15 trials involving a total of 1437 infants. All trials were small (median number of participants 88). The methods used to generate the randomisation sequence and ensure allocation concealment were unclear in about half of the trial reports. Lack of measures to blind caregivers or investigators was a potential source of bias in all of the included trials. The trials took place during the past 25 years in care facilities internationally, predominantly in India (five trials) and Iran (four trials). The studied pressure sources were commercially available bubble CPAP devices versus a variety of mechanical ventilator (11 trials) or Infant Flow Driver (4 trials) devices. Meta-analyses suggest that the use of bubble CPAP compared with mechanical ventilator or Infant Flow Driver CPAP may reduce the rate of treatment failure (RR 0.76, 95% confidence interval (CI) 0.60 to 0.95; (I² = 31%); RD -0.05, 95% CI -0.10 to -0.01; number needed to treat for an additional beneficial outcome 20, 95% CI 10 to 100; 13 trials, 1230 infants; low certainty evidence). The type of pressure source may not affect mortality prior to hospital discharge (RR 0.93, 95% CI 0.64 to 1.36 (I² = 0%); RD -0.01, 95% CI -0.04 to 0.02; 10 trials, 1189 infants; low certainty evidence). No data were available on neurodevelopmental impairment. Meta-analysis suggests that the pressure source may not affect the risk of pneumothorax (RR 0.73, 95% CI 0.40 to 1.34 (I² = 0%); RD -0.01, 95% CI -0.03 to 0.01; 14 trials, 1340 infants; low certainty evidence). Bubble CPAP likely increases the risk of moderate-severe nasal injury (RR 2.29, 95% CI 1.37 to 3.82 (I² = 17%); RD 0.07, 95% CI 0.03 to 0.11; number needed to treat for an additional harmful outcome 14, 95% CI 9 to 33; 8 trials, 753 infants; moderate certainty evidence). The pressure source may not affect the risk of bronchopulmonary dysplasia (RR 0.76, 95% CI 0.53 to 1.10 (I² = 0%); RD -0.04, 95% CI -0.09 to 0.01; 7 trials, 603 infants; low certainty evidence). AUTHORS' CONCLUSIONS: Given the low level of certainty about the effects of bubble CPAP versus other pressure sources on the risk of treatment failure and most associated morbidity and mortality for preterm infants, further large, high-quality trials are needed to provide evidence of sufficient validity and applicability to inform context- and setting-relevant policy and practice.

Drug-induced sleep endoscopy-continuous positive airway pressure (DISE-CPAP), a newer modality to choose the right candidates for CPAP.

Continuous positive airway pressure (CPAP) therapy is recommended for moderate-to-severe obstructive sleep apnea (OSA). We aimed to investigate whether or notcombining drug-induced sleep endoscopy (DISE) with CPAP titration may inform more appropriate pressure settings. A sleep CPAPtitration study and DISE-CPAP treatment were performed on consecutive subjects with moderate-to-severe OSA under controlled sedation using bispectral monitoring. Video recordings of dynamic changes in UA with CPAP pressure ranges of 5 to 25cm were assessed in accordance with the VOTE classification. The 95th percentile (95th PC) pressure of the CPAP titration trial was compared to optimal pressure for alleviating UA blockage. We included 30 subjects (mean age 37.5, 17% women). All showed UA collapse at more than one level, with more than 80% of them collapsing completely at the levels of thevelum and oropharynx. At the velum, 90% of subjects experienced improvement with CPAP. At the oropharynx, 75% of subjects experienced improvement with CPAP. The meanpressureand standard deviation (SD) of the 95th PC of the CPAP titration was 14.3 (3.5) cmH2O, while the pressure required to partially or fully open the airway (best possiblepressure) was 16.1 (3.9) cmH2O; mean (SD) difference, 1.9 (2.2); P ≤ 0.001. The limits of agreement between the CPAP 95th pressure and the ideal pressure were - 6.32 to + 2.52. The palate and lateral pharynx were more affected by CPAP than the hypopharynx. Most of the time, the mean 95th PC CPAP titration pressure was lower than the mean optimal pressure needed to alleviate the collapse.

Adherence to CPAP Three Months after Starting Therapy in 1078 Patients with Obstructive Sleep Apnea (OSA)

Nocturnal Continuous Positive Airway Pressure (CPAP) is considered the gold standard treatment for obstructive sleep apnoea (OSA). The CPAP therapy is a long-term treatment but does come with few possible side effects. The adherence to the therapy is frequently suboptimal. In this paper, adherence to therapy was assessed and typical problems were classified. 1078 OSA patients received CPAP therapy after a diagnostic polygraphy (PG) or polysomnography (PSG). Adherence to therapy was followed up three months after treatment induction. The following therapy adherence groups were defined: 1. correctly calibrated CPAP and good adherence, 2. CPAP non-acceptance, after initial use, 3. CPAP intolerance use due to side effects, 4. discontinuation due to lack of motivation/low rates of symptoms. 5. mask intolerance, 6. CPAP failure due to a lack of perceived treatment effect, 7. Change to another non-invasive ventilation method, 8. No control carried out. Out of 1078 OSA patients a therapy control was performed in 830 patients (77%). Of these, 450 patients (54.2%) were placed in group 1, 216 patients (26 %) in group 2, 71 patients (8.5 %) in group 3, 35 patients (4.2 %) in group 4, 14 patients (1.7 %) in group 5, 3 patients (0.4 %) in group 6 and 41 patients (4.9%) in group 7. A mild obstructive index, low CPAP pressure and, as a trend, a low Epworth-Sleepiness score were predictors of CPAP failure. No significant predictors could be shown for adherence to therapy. An effective treatment use of 54% after 3 months is a suboptimal result. Predictors of CPAP failure were parameters that indicated that the patient was less symptomatic prior to therapy. Despite a large patient cohort, neither anthropometric nor PSG-data provided any significant CPAP adherence predictors. Rather, experiences in the first nights of use could be decisive. CPAP devices offer comfort settings that have to be personalised to patients' needs and wants. A large selection of different mask shapes requires experience and training in patient-centred mask fitting. A three-month follow-up appointment seems too long to discuss therapy problems with the patient in a timely manner. Telemedical options or short-term telephone appointments should be considered.

The effect of continuous positive airway pressure on inferior vena cava collapsibility as measured by bedside ultrasound.

The purpose of this study was to determine the impact of progressively increasing continuous positive airway pressure (CPAP) on measurements of the caval index (CI) using bedside ultrasound at the 3 common inferior vena cava (IVC) evaluation sites. This was a prospective, observational trial that included 165 healthy adults over 18 years old enrolled between February 2015 and May 2018. Measurements of the IVC were obtained during normal tidal respirations from the subxiphoid area in the long and short axis and from the right mid-axillary line in the long axis. Measurements were obtained in each of these locations at atmospheric pressure and with CPAP at 5, 10, and 15 cmH2O. The CI was then calculated for each of the 3 selected locations at each level of pressure. As CPAP pressures increased from 0 to 15cmH2O the CI measurements obtained at the lateral mid-axillary line did not show any statistically significant variation. There was a statistically significant difference (P<0.001) when comparing measurements of the CI from the lateral mid-axillary line location to both anterior locations. As CPAP pressures increased, the CI calculated from the subxiphoid area in both the anterior short and anterior long axis orientations initially trended upwards at 5cmH2O, then began to downtrend as the pressures increased to 10 and 15cmH2O. Comparing the CI measurements from the anterior long and anterior short axis at 0, 5, 10, and 15cmH2O, there was no statistically significant difference at any pressure (P>0.05). When evaluating the IVC in a spontaneously breathing patient, measurements from an anterior orientation are preferred as the lateral mid-axillary view can underestimate CI calculations.

Correlation between Neck Circumference and Continuous Positive Airway Pressure among Patients of Obstructive Sleep Apnea

Objective: To investigate the relationship between neck circumference (NC) and continuous positive airway pressure (CPAP) in patients with obstructive sleep apnea (OSA), as well as to assess CPAP requirements based on the neck circumference. Material and methods: This study was carried out in the pulmonary, vascular, and sleep disorders department of the Dow University Hospital in Karachi. The study was done for six months of duration from January 2022 to June 2022. All of the patients who had obstructive sleep apnea (OSA), between the ages of 18 and 60 years, both genders and underwent CPAP therapy were chosen for this study. The polysomnography database was utilized in order to do an analysis on the Apnea-Hypopnea Index for the OSA. Neck circumference was measured at the neck’s middle sit in every participant. The neck circumference was correlated with the CPAP therapy. The structured study proforma was used to collect all the data. Results: A total of 181 individuals who presented with OSA were studied. Mean age of the cases were 52.86+12.26 years and mean neck circumference was 43.45+3.58 cm. Males were 58.0% and females were 42.0%. Majority of the cases 56.4% had severe OSA. There was a strong significant positive correlation between neck circumference and CPAP (r= 0.177, p-value 0.017) and significant positive correlation between neck circumference and CPAP (r= 0.366, p-value 0.001). Average of CPAP pressure was significantly high according to severity of OSA (p-0.0001). Conclusion: The neck circumference was observed to be the most reliable marker that significantly positively correlated with CPAP therapy and measurements of OSA and its severity, by AHI alone, seem to have a positive correlation with CPAP therapy. However, OSA evaluation and treatment can be measured for their responsiveness to CPAP based on their neck circumference. Keywords: OSA, NC, CPAP, Relationship

Effects of using in-line bacterial filters with continuous positive airway pressure devices in patients with sleep disordered breathing

In June 2021, Philips Respironics first advised the use of in-line bacterial filters in response to a recall of continuous positive airway pressure (CPAP) devices. However, the effects of using in-line filters with CPAP devices have not yet been examined in a clinical setting. Here, we retrospectively evaluated 160 patients with sleep-disordered breathing (SDB) who voluntarily used in-line bacterial filters. Patients’ perceptions of CPAP pressure after using in-line filters were investigated via a verbal interview. Patients described CPAP pressure as very weak (13, 8.1%), somewhat weak (42, 26.2%), unchanged (103, 64.4%), or somewhat strong (2, 1.3%). Five of the thirteen patients (38.5%) who described CPAP pressure as very weak discontinued the use of in-line filters. The apnea–hypopnea index obtained from the CPAP devices did not change after using in-line filters (n = 129, p = 0.85). Hence, although in-line bacterial filters could change patients’ perceptions of CPAP pressure, they did not influence SDB control.

Upper airway multilevel radiofrequency under local anesthesia can improve CPAP adherence for severe OSA patients

ObjectiveTo evaluate the effect of upper airway radiofrequency (RF) tissue reduction under local anesthesia (LA) in severe obstructive sleep apnea (OSA) patients using continuous positive airway pressure (CPAP) in order to improve their compliance and adherence. DesignThirty (30) patients were included in this randomized clinical trial, suffering from severe OSA seeking medical advice for better upper airway management while using CPAP. Multilevel RF tissue reduction at tongue base, soft palate and inferior nasal turbinates was done under LA in multiple sessions. The Apnea hypopnea index (AHI), arousal index, lowest SpO2, CPAP pressure, and CPAP using time were recorded pre-operatively and six months after the last RF session. ResultsPost-operatively, there were significant reduction in AHI (86.03 ± 20.5 vs. 54.65 ± 16.6 p < 0.001), arousal index (71.14 ± 17.7 vs. 35.90 ± 11.8 p < 0.001), and CPAP Pressure (17.13 ± 1.7 vs. 10.97 ± 1.5 p < 0.001). Also there was a significant increase in the lowest SpO2 (60.2 ± 0.2 vs. 75 ± 0.1 p < 0.001), and CPAP using time in hours (1.57 ± 0.56 vs. 3.75 ± 0.41 p < 0.001). Visual analogue scale (VAS) for pain was recorded showing that all patients reported throat pain mainly in the first five post-operative days which was well controlled on analgesia. Conclusion and relevanceUpper airway multilevel RF tissue reduction of tongue base, soft palate and inferior nasal turbinates under local anesthesia significantly improves the tolerance and adherence of severe OSA patients using CPAP.

Nasal pillow vs. standard nasal mask for treatment of OSA: a systematic review and meta-analysis.

The purpose of this study was to compare the effectiveness of nasal pillows with standard nasal masks in the treatment of patients with obstructive sleep apnea (OSA). A digitalized search was carried out in four different databases including PubMed, Scopus, EMBASE, and CENTRAL using relevant keywords along with a manual search in relevant journals. All comparative studies comparing outcomes of using a nasal pillow with the use of standard nasal masks for continuous positive airway pressure (CPAP) treatment in patients with OSA were included. The qualitative analysis was carried out by tabulating the demographic data. The quantitative data were subjected to meta-analysis. The quality of comparative studies (both retrospective and prospective cohorts) was evaluated using New-castle Ottawa scale (NOS). A total of 14 studies (eight prospective and six retrospective) were included in the review. Of them, five studies were randomized and were of cross-over study design. No significant differences were observed in achieved CPAP and residual apnea-hypopnea index (AHI) levels between the nasal pillow and nasal mask with SMD - 0.05 95% CI [- 0.18, 0.09], p = 0.50 and SMD - 0.13 95% CI [- 0.28, 0.03], p = 0.12, respectively. However, nasal pillow usage was associated with better CPAP adherence with a difference of only + 0.29min/night as compared to a standard nasal mask, with SMD 0.29 95% CI [0.07, 0.50], p = 0.009. Nasal pillow and standard nasal mask were equally effective in terms of residual AHI level and achieved similar therapeutic CPAP pressures. However, the difference in CPAP adherence between groups, though statistically significant, is of questionable clinical significance.

Outcome of CPAP Titration for Moderate-to-Severe OSA Under Drug-Induced Sleep Endoscopy: A Randomized Controlled Crossover Trial.

BackgroundThe titration pressure of continuous positive airway pressure (CPAP) is important in patients with obstructive sleep apnea (OSA). This study aimed to understand the difference between drug-induced sleep endoscopy (DISE)-guided CPAP titration and conventional sleep center (CSC) CPAP titration in patients with OSA.MethodsIn this randomized, controlled, and single-blind crossover trial, we compared the effects of 1-month CPAP treatment in patients with OSA with either DISE-guided CPAP titration or CSC CPAP titration. Twenty-four patients with OSA were recruited for the study. All patients underwent polysomnography, DISE-guided CPAP titration, and accommodation. Initially, patients were randomly assigned to receive either DISE-guided CPAP titration or CSC CPAP treatment for the first month. They were then switched to other treatments in the second month. The Epworth sleepiness scale (ESS) score was recorded at baseline, 1 and 2 months.ResultsThe upper limit of the pressure of DISE-guided titration and CSC CPAP titration was not significantly different (13.9 ± 0.7 vs. 13.5 ± 0.5 cm H2O; P = 0.92). The residual apnea-hypopnea index and compliance were also not significantly different between the groups. ESS score significantly improved from baseline to 1 month after CPAP treatment in both groups. Both epiglottis (anterior-posterior collapse) and tongue base collapse were significantly associated with 95% CPAP pressure (P = 0.031 and 0.038, respectively). After multivariate regression analyses, the epiglottis (anterior-posterior collapse) was an independent factor for 95% CPAP pressure. The incidence rate of bradycardia was 58.3%, which is a safety concern for DISE. Despite the high incidence of bradycardia, all patients with bradycardia recovered with proper management.ConclusionBoth modalities were comparable in terms of establishing the pressure settings required to treat patients. Further large-scale studies are required to confirm these results.Trial registrationhttps://clinicaltrials.gov/, NCT03523013.

Noninvasive Ventilation and Exogenous Surfactant in Times of Ever Decreasing Gestational Age: How Do We Make the Most of These Tools?

Noninvasive Ventilation and Exogenous Surfactant in Times of Ever Decreasing Gestational Age: How Do We Make the Most of These Tools?

Preterm Infant with Respiratory Distress, Hypotonia, and Hypoglycemia.

Preterm Infant with Respiratory Distress, Hypotonia, and Hypoglycemia.

Impact of Upper Airway Characteristics on Disease Severity and CPAP Therapy in Chinese Patients With OSA: An Observational Retrospective Study.

ObjectiveThe characteristics of the upper airway (UA) are important for the evaluation and treatment of obstructive sleep apnea (OSA). This study aimed to investigate the association of UA characteristics with OSA severity, titration pressure, and initiation of and 3-month compliance with continuous positive airway pressure (CPAP).MethodsThis retrospective study included consecutive patients examined using a semi-quantitative UA evaluation system (combination with physical examination and awake endoscopy) during 2008–2018 at the Department of Respiratory and Critical Care Medicine, Peking University First Hospital. First, the differences in UA characteristics were compared between patients with simple snorers and mild OSA and those with moderate-to-severe OSA. Then, the effect of UA characteristics on the initiation to CPAP therapy and 3-month adherence to CPAP was conducted.ResultsOverall, 1,002 patients were included, including 276 simple snorers and patients in the mild OSA group [apnea-hypopnea index (AHI) <15] and 726 patients in the moderate-to-severe OSA group (AHI ≥15). Tongue base hypertrophy, tonsillar hypertrophy, mandibular recession, neck circumstance, and body mass index (BMI) were independent risk factors for moderate-to-severe OSA. Among those patients, 119 patients underwent CPAP titration in the sleep lab. The CPAP pressures in patients with thick and long uvulas, tonsillar hypertrophy, lateral pharyngeal wall stenosis, and tongue hypertrophy were higher than those of the control group (P < 0.05, respectively). The logistic regression analysis showed that nasal turbinate hypertrophy, mandibular retrusion, and positive Müller maneuver in the retropalate and retroglottal regions were independent predictors for the initiation of home CPAP treatment.ConclusionMultisite narrowing and function collapse of the UA are important factors affecting OSA severity, CPAP titration pressure, and the initiation of home CPAP therapy. Clinical evaluation with awake endoscopy is a safe and effective way for the assessment of patients with OSA in internal medicine.