CPAP-treated Patients Research Articles

CARDIOVASCULAR RISK ASSESSMENT IN A FOLLOW-UP OF HYPERTENSIVE PATIENTS WITH OBSTRUCTIVE SLEEP APNEA SYNDROME IN ST PETERSBURG: PP.32.286

Objective: To estimate the impact of obstructive sleep apnea/hypopnea syndrome (OSAHS) on cardiovascular morbidity and mortality and changes of the main cardiovascular risk (CVR) factors. Design and Methods: 147 hypertensive patients (90 males), aged 23–80 years (mean 52.1 ± 10.4 years) were recruited in May 2003-March 2007. Based on the sleep study (Embletta Pds, Embla, USA) patients were divided into 2 groups. The control group included 42 non-OSAHS patients (apnea/hypopnea index (AHI)<5/h), the second group – 105 OSAHS patients (mean AHI 32.9 ± 20.0/h). Twelve (23.5%) patients from the second group receiving regular CPAP-therapy at home formed the third subgroup. The patients were examined twice per year. The primary (a composite of CV death, fatal/non-fatal myocardial infarction and stroke) and secondary (hospitalization for new or worsened CV disease) endpoints were assessed. Non-parametric statistics, Kaplan-Meier analysis and Cox proportional hazards model were used for data analysis. Results: By March 2009 the mean follow-up period was 46.4 ± 14.3 months. Overall, events were registered in 23 patients (15.6%), including 13 deaths (8.8%) (mean age 55.5 ± 10.9 years). 20.4% untreated OSAHS patients achieved primary endpoint compared to 8.3% in CPAP-treated and 2.4% in control group. CVR was significantly higher in untreated OSAHS patients than in controls (OR = 8.557 95%CI 1.142–64.131, p = 0.037), but similar to CPAP-treated patients (OR = 0.379 95%CI 0.045–3.127, p = 0.690). CPAP-treated patients and controls had the same risk as well (OR = 3,727 95%CI 0.215–64.574, p = 0.398). Severe OSAHS was a significant indicator of a poor prognosis (OR = 9.203 95%CI 1.176–72,002, p = 0.034) independently of other variables (sex, age, body mass index, hypertension duration, smoking, alcohol use, level of physical activity, family history, coronary artery disease, glucose metabolism impairment), while mild-to-moderate OSAHS did not affect survival (OR = 8.588 95%CI 0.999–73.82 and OR = 4.205 95%CI 0.437–40.434, p > 0.05). Untreated OSAHS patients had higher hospitalization rate compared to controls (OR 2.750 95%CI 1.100–6.873, p = 0.04). Conclusions: This study confirmed that OSAHS patients, in particular those with severe OSAHS (AHI>=30/h), have higher CVR, poor outcome, and higher hospitalization rate for CV disease.

CPAP compliance in patients with obstructive sleep apnea syndrome

Obstructive sleep apnea syndrome (OSAS) is characterized by repeated cessations of breathing during sleep. Major symptoms of this disease are excessive daytime sleepiness, snoring, and witnessed apnea. Most of the patients are treated with CPAP. In this study, we aimed to evaluate the factors affecting adherence to the CPAP treatment. Seventy-one patients were enrolled to this study. Patients were divided into three groups according to CPAP usage. Group I consisted of patients who had never used CPAP, group II consisted of patients who had used CPAP occasionally, and group-III patients had used CPAP treatment regularly. Group-III patients had higher apnea-hypopnea index (AHI) than groups I and II (respectively, 56.6 +/- 27.7, 26.3 +/- 7.5, and 32.3 +/- 7.06; p < 0.000 for both). Oxygen desaturation index was significantly higher in group-III patients comparing to groups I and II (44.6 +/- 22.3, 15.9 +/- 8.3, and 25.6 +/- 9.5; p < 0.000 for all). Our findings have shown that only very severe patients use the CPAP device regularly (mean AHI 56.6 +/- 27.7). Compliance to CPAP treatment seemed to be poor in patients with moderate to severe, AHI about 30, OSAS. Considering the well-established benefits of CPAP treatment in patients with true indications, patients should be encouraged to use CPAP regularly, and complications of OSAS should be keynoted.

1381 Validity and reliability of the Side Effects to CPAP treatment Inventory: A tool for measuring side effects to CPAP treatment in patients with obstructive sleep apnoea

Validity and reliability of the Side Effects to CPAP treatment Inventory: A tool for measuring side-effects to CPAP treatment in patients with obstructive sleep apnoea

1382 The Informational Needs to CPAP treatment Inventory: A description of a new self-assessment tool in CPAP-treated patients with obstructive sleep apnoea

The Informational Needs to CPAP treatment Inventory: A description of a new self-assessment tool in CPAP-treated patients with obstructive sleep apnoea

Prognosis of Patients With Heart Failure and Obstructive Sleep Apnea Treated With Continuous Positive Airway Pressure

Therapy with continuous positive airway pressure (CPAP) provides several benefits for patients with heart failure (HF) complicated by obstructive sleep apnea (OSA). However, the effect on the prognosis of such patients remains unknown. To determine whether CPAP therapy and compliance affects the prognosis of HF patients with OSA. We classified 88 patients with HF and moderate-to-severe OSA into a CPAP-treated group (n = 65) and an untreated group (n = 23), and then those treated with CPAP were further subclassified according to CPAP therapy compliance. The frequency of death and hospitalization was analyzed using multivariate analysis. During a mean (+/- SD) period of 25.3 +/- 15.3 months, 44.3% of the patients died or were hospitalized. Multivariate analysis showed that the risk for death and hospitalization was increased in the untreated group (hazard ratio [HR], 2.03; 95% confidence interval [CI], 1.07 to 3.68; p = 0.030) and in less compliant CPAP-treated patients (HR, 4.02; 95% CI, 1.33 to 12.2; p = 0.014). Therapy with CPAP significantly reduced the risk of death and hospitalization among patients with HF and OSA. However, reduced compliance with CPAP therapy was significantly associated with an increased risk of death and hospitalization.

Association of Type D personality to perceived side effects and adherence in CPAP‐treated patients with OSAS

Continuous positive airway pressure (CPAP) is the treatment of choice for obstructive sleep apnoea syndrome (OSAS), but side effects are common and long-term adherence low. The Type D (distressed) personality is defined as a combination of negative affectivity and social inhibition. The association of Type D personality with adherence has not been studied in CPAP-treated patients with OSAS. This study aimed to describe the prevalence of Type D personality in OSAS patients with CPAP treatment longer than 6 months and the association with self-reported side effects and adherence. A cross-sectional descriptive design was used. A total of 247 OSAS patients with a mean use of CPAP treatment for 55 months (6-182 months) were included. Data collection was achieved by two questionnaires; the Type D scale 14 (DS14) (Type D personality), SECI (side effects of CPAP), as well as from medical records (clinical variables and objective adherence to CPAP treatment). Type D personality occurred in 30% of the patients with OSAS and significantly (P < 0.05-0.001) increased the perceived frequency and severity of a broad range of side effects. The objective adherence was significantly lower (P < 0.001) for OSAS patients with Type D compared to OSAS patients without Type D, both with regard to a mean use of 4 h per night and 85% of the self-rated sleep time per night. The additional effect of a Type D personality on perceived side effects and adherence to CPAP treatment found in this study could be used by healthcare personnel when evaluating patients waiting for treatment.

Effectiveness of Prehospital Continuous Positive Airway Pressure in the Management of Acute Pulmonary Edema

Objective. To compare the effectiveness of continuous positive airway pressure (CPAP) with standard pharmacologic treatment in the management of prehospital acute pulmonary edema. Methods. Using a nonrandomized control group design, all consecutive patients presenting to two participating emergency medical services (EMS) systems with a field impression of acute pulmonary edema between July 1, 2004, andJune 30, 2005, were included in the study. The control EMS system patients received standard treatment with oxygen, nitrates, furosemide, morphine, and, if indicated, endotracheal intubation. The intervention EMS system patients received CPAP via face mask at 10 cm H2O in addition to standard therapy. Results. Ninety-five patients received standard therapy, and120 patients received CPAP andstandard therapy. Intubation was required in 8.9% of CPAP-treated patients compared with 25.3% in the control group (p = 0.003), andmortality was lower in the CPAP group than in the control group (5.4% vs. 23.2%; p = 0.000). When compared with the control group, the CPAP group had more improvement in respiratory rate (−4.55 vs. −1.81; p = 0.001), pulse rate (−4.77 vs. 0.82; p = 0.013), anddyspnea score (−2.11 vs. −1.36; p = 0.008). Using logistic regression to control for potential confounders, patients receiving standard treatment were more likely to be intubated (odds ratio, 4.04; 95% confidence interval, 1.64 to 9.95) andmore likely to die (odds ratio, 7.48; 95% confidence interval, 1.96 to 28.54) than those receiving standard therapy andCPAP. Conclusion. The prehospital use of CPAP is feasible, may avert the need for endotracheal intubation, andmay reduce short-term mortality.

Long-term Effects of Nasal Continuous Positive Airway Pressure Therapy on Cardiovascular Outcomes in Sleep Apnea Syndrome

Obstructive sleep apnea syndrome (OSAS) has been associated with increased morbidity and mortality, principally from cardiovascular disease, but the impact of nasal continuous positive airway pressure (CPAP) therapy is unclear. We performed a long-term follow-up study of 168 patients with OSAS who had begun receiving CPAP therapy at least 5 years previously, most of whom had been prospectively followed up, having been the subject of an earlier report on cardiovascular risk factors in OSAS patients. The average follow-up period was 7.5 years. We compared the cardiovascular outcomes of those patients who were intolerant of CPAP (untreated group, 61 patients) with those continuing CPAP therapy (107 patients). CPAP-treated patients had a higher median apnea-hypopnea index score than the untreated group (48.3 [interquartile range (IQR), 33.6 to 66.4] vs 36.7 [IQR, 27.4 to 55], respectively; p = 0.02), but age, body mass index, and time since diagnosis were similar. Deaths from cardiovascular disease were more common in the untreated group than in the CPAP-treated group during follow-up (14.8% vs 1.9%, respectively; p = 0.009 [log rank test]), but no significant differences were found in the development of new cases of hypertension, cardiac disorder, or stroke. Total cardiovascular events (ie, death and new cardiovascular disease combined) were more common in the untreated group than in the CPAP-treated group (31% vs 18%, respectively; p < 0.05). The data support a protective effect of CPAP therapy against death from cardiovascular disease in patients with OSAS.

Inhibition of Awake Sympathetic Nerve Activity of Heart Failure Patients With Obstructive Sleep Apnea by Nocturnal Continuous Positive Airway Pressure

This study was designed to determine whether reductions in morning systolic blood pressure (BP) elicited by treatment of moderate to severe obstructive sleep apnea (OSA) in heart failure (HF) patients are associated with a reduction in sympathetic vasoconstrictor tone. Daytime muscle sympathetic nerve activity (MSNA) is elevated in HF patients with coexisting OSA. In our recent randomized trial in HF, abolition of OSA by continuous positive airway pressure (CPAP) increased left ventricular ejection fraction (LVEF) and lowered morning systolic BP. Muscle sympathetic nerve activity, BP, and heart rate (HR) of medically treated HF patients (EF <45%) and OSA (apnea-hypopnea index > or =20/h of sleep) were recorded on the morning after overnight polysomnography, and again one month after patients were randomly allocated nocturnal CPAP treatment or no CPAP (control). In nine control patients, there were no significant changes in the severity of OSA, MSNA, systolic BP, or HR. In contrast, in the 8 CPAP-treated patients, OSA was attenuated, and there were significant reductions in daytime MSNA (from 58 +/- 4 bursts/min to 48 +/- 5 bursts/min; 84 +/- 4 bursts/100 heart beats to 72 +/- 5 bursts/100 heart beats; p < 0.001 and p = 0.003, respectively), systolic BP (from 135 +/- 5 mm Hg to 120 +/- 6 mm Hg, p = 0.03), and HR (from 69 +/- 2 min(-1) to 66 +/- 2 min(-1); p = 0.013). Treatment of coexisting OSA by CPAP in HF patients lowers daytime MSNA, systolic BP, and HR. Inhibition of increased central sympathetic vasoconstrictor outflow is one mechanism by which nocturnal CPAP reduces awake BP in HF patients with moderate to severe OSA.

Periodic limb movements and sleepiness in obstructive sleep apnea patients

Background and purpose The aim of this study was to assess the possibility that periodic limb movements during sleep (PLMS) could play an additive role in the sleepiness associated with obstructive sleep apnea syndrome (OSAS) before treatment, or could account for residual sleepiness in successfully CPAP-treated patients. Patients and methods In order to test this hypothesis, we compared objective sleepiness, assessed by the Multiple Sleep Latency Test (MSLT) and subjective sleep propensity, assessed by the Epworth Sleepiness Scale (ESS), in a clinical series of 57 patients consecutively diagnosed with OSAS (apnea/hypopnea index, 53.3±26.15), before and after 1 year of treatment with CPAP. Results Twenty-two patients (38.5%) had significant PLMS (at least 5 PLMS/h of sleep; mean 52.9±53.9) in absence of apneas (with CPAP). The two groups (with and without PLMS) were similar in gender distribution, BMI, apnea/hypopnea index or CPAP level. Patients with PLMS were older than those without PLMS. Sleepiness measurements following OSAS diagnosis and after 1 year of CPAP treatment were similar in patients PLMS compared to those without significant PLMS. There was no correlation in the PLMS patient group between the PLM index, Epworth Sleepiness Scale score and mean latency in the MSLT. Conclusion In this study we did not find a link between PLMS and increased objective or self-evaluated sleepiness in OSAS patients, before or after treatment with CPAP.

T HE U SE OF P REHOSPITAL C ONTINUOUS P OSITIVE A IRWAY P RESSURE T REATMENT IN P RESUMED A CUTE S EVERE P ULMONARY E DEMA

Objective. To describe the prehospital use of a continuous positive airway pressure (CPAP) system for the treatment of presumed acute severe pulmonary edema (ASPE). Methods. The efficacy of prehospital CPAP treatment was analyzed in terms of changes in oxygen saturation, need for intubation or ventilatory support, and possible morbidity associated with the CPAP therapy. This was a retrospective cohort study conducted in the mobile intensive care unit of a university hospital. Participants included all consecutive patients with a clinical picture of ASPE treated by a mobile intensive care unit between January 1, 1998, and December 31, 1999. Results. 121 patients were included in this study. 116 patients received prehospital CPAP therapy. Two patients (1.7%) from the CPAP-treated patients were intubated in the field. A total of six patients required endotracheal intubation before hospital, and six other patients after that. After the beginning of CPAP treatment, there was statistically significant elevation in blood oxygen saturation (mean and standard deviation [SD] before CPAP 77% ± 11% and after CPAP 90% ± 7%) (p < 0.0001) as well as reductions in the respiratory rate (mean and SD before CPAP 34 ± 8 breaths/min and after CPAP 28 ± 8 breaths/min) (p < 0.0001), systolic blood pressure (mean and SD before CPAP 173 ± 39 mm Hg and after CPAP 166 ± 37 mm Hg) (p = 0.0002), and heart rate (mean and SD before CPAP 108 ± 25 beats/min and after CPAP 100 ± 20 beats/min) (p = 0.0017). The main reason for in-hospital death (8%) was myocardial infarction. No technical problems or complications occurred during CPAP treatment. Conclusions. Prehospital CPAP treatment in patients with ASPE improved oxygenation significantly and lowered respiratory rate, heart rate, and systolic blood pressure. Because of the retrospective nature of this study, the hemodynamic effects of nitroglycerine and morphine cannot be excluded. The mortality rate was low, which needs to be confirmed in a controlled, prospective study.

Chronic insomnia, premenopausal women and sleep disordered breathing: Part 2. Comparison of nondrug treatment trials in normal breathing and UARS post menopausal women complaining of chronic insomnia

Objective: The question addressed here is: Can a discrete sleep disordered breathing (SDB) play a role in the insomnia complaint of postmenopausal chronic insomniacs? To respond to the query, two groups of individuals derived from a cohort of postmenopausal chronic insomniacs recruited mostly from the community were enlisted in a treatment protocol. These subjects were all individuals identified with normal breathing ( n=68) and all those recognized with Upper Airway Resistance Syndrome (UARS) ( n=62) pooled from a cohort of 349 postmenopausal insomniacs. Treatment protocol: The 62 UARS were allocated to either treatment of chronic insomnia by behavioral approaches or treatment of SDB. Based on ENT evaluation, health professionals in charge of patients selected either treatment with nasal CPAP or treatment of nasal turbinates. A stratification correction was performed to obtain a near equal number of both treatment modalities in each of the two subgroups. The 68 individuals with normal breathing were randomly allocated to immediate behavioral treatment of insomnia or delay treatment of insomnia. The delay treatment received a list of 10 sleep hygiene recommendations by mail. Methodology: Questionnaires, visual analog scales (VAS), Epworth Sleepiness Scale (ESS), clinical interviews, clinical evaluation with oto-laryngologic clinical assessment of a presence/absence of narrow upper airway and location of narrowing. Actigraphy and polysomnography (PSG) with pressure transducer/and nasal cannula system and esophageal manometry. Data analyses: All recording data were scored blind to patient's condition. Results: Two subjects in the SBD-CPAP treated group (Group B) and two subjects in the delayed treatment group (Group D) dropped out. Total sleep time was improved compared to baseline in all groups, including the delayed treatment group. One group was significantly better (ANOVA, P=.05) with a more important δ score compared to baseline, and this was the behaviorally treated non-SDB. Sleep latency was significantly decreased in the behaviorally treated group (with or without SBD), P=.05, compared to SBD-treated and d elayed treatment groups. Sleep latency was, however, improved in all groups. VAS for “quality of sleep” was higher at 6 months in all the groups when compared to “baseline” values. VAS for “daytime fatigue” showed significant differences among the four groups (ANOVA, P=.01); the overall score at the end of treatment was significantly better in the SDB-treated group than the other three groups. SBD was treated either by radio frequency on nasal turbinate or by nasal CPAP. CPAP-treated patients had a lower VAS score than nasal turbinate treatment, but the difference was only a trend. The δ improvement (6-month baseline condition) in “daytime fatigue” of each subgroup was calculated and compared within and between groups. Despite the small number of subjects, the turbinate-treated subgroup was significantly different from Groups B, C and D (ANOVA, P=.05). When a similar comparison was made with the nasal CPAP group, there was only a nonsignificant trend when compared to Groups B, C and D. Conclusion: Abnormal breathing during sleep significantly enhanced complaints of daytime fatigue in postmenopausal chronic insomniacs and this complaint improved with SDB treatment. This improvement is significantly better compared to SDB insomniacs treated with a behavioral regimen. Behavioral treatment, however, gave the best response in the non-SDB chronic insomnia group and improved better long sleep latency even in the SDB group. These results suggest the need to find an appropriate treatment for SBD even if mild and to recognize the role of SDB in relation to symptoms seen with chronic insomnia.

Safety and Efficacy of Postoperative Continuous Positive Airway Pressure to Prevent Pulmonary Complications After Roux-en-Y Gastric Bypass

Continuous positive airway pressure (CPAP) is used to prevent apneic arrest and/or hypoxia in patients suffering from obstructive sleep apnea. This modality has not been universally accepted for patients following upper gastrointestinal surgery because of concerns that pressurized air will inflate the stomach and proximal intestine, resulting in anastomotic disruption. This study was performed to assess the safety and efficacy of postoperative CPAP for patients undergoing a gastrojejunostomy as part of a Roux-en-Y gastric bypass (RYGB) procedure. A total of 1067 patients (837 women [78%] and 230 men [22%]) were prospectively evaluated for the risk of developing anastomotic leaks and pulmonary complications after the RYGB procedure. Of the 1067 patients undergoing gastric bypass, 420 had obstructive sleep apnea and 159 were dependent on CPAP. There were 15 major anastomotic leaks, two of which occurred in CPAP-treated patients. Contingency table analysis demonstrated that there was no correlation between CPAP utilization and the incidence of major anastomotic leakage ( P = 0.6). Notably, no episodes of pneumonia were diagnosed in either group. Despite the theoretical risk of anastomotic injury from pressurized air delivered by CPAP, no anastomotic leaks occurred that were attributable to CPAP. There were no pulmonary complications in a patient population that is at risk for developing them postoperatively. CPAP is a useful modality for treating hypoventilation after RYGB without increasing the risk of developing postoperative anastomotic leaks. ( J Gastrointest Surg 2002;6:354–358.)

Continuous Positive Airway Pressure Normalizes Cardiac Autonomic and Hemodynamic Responses to a Laboratory Stressor in Apneic Patients

We examined the effect of continuous positive airway pressure (CPAP) treatment for sleep apnea on cardiac contractility, heart rate variability, and hemodynamics at rest and in response to a laboratory stressor. SUBJECTS AND INSTRUMENTATION: Forty-one apneic patients were studied on three occasions: before treatment, after 1 full night of CPAP treatment, and after 1 week of CPAP treatment. The subjects were randomly assigned to receive effective treatment or placebo. Contractility and hemodynamics were determined with impedance cardiography, and parasympathetic activity was assessed by analysis of heart rate variability. Measures were determined at rest and in response to a stressor. For the cardiac sympathetic (contractility) measures (preejection period, cardiac acceleration index [CAI], and low-frequency/high-frequency ratio) significant interactions were found in the combination treatment (CPAP vs placebo) by study day (day 1, day 3, day 11) by test period (baseline, preparation, talking) [p < 0.01]. For these measures, there were no differences between the treatment groups or responses to the stressor on day 1. Levels in placebo-treated subjects did not change or respond on the subsequent study days. In the CPAP-treated subjects, there was a decrease in these indexes at baseline, which became significantly lower by day 11 (ie, CAI levels were 24 Omega/s(2), 22 Omega/s(2), and 14 Omega/s(2) on day 1, day 3, and day 11, respectively). These measures also became responsive to the stressor by showing increased sympathetic activity (CAI levels on day 11 were 14 Omega/s(2) at baseline, 32 Omega/s(2) during speech preparation, and 36 Omega/s(2) while speaking). The parasympathetic indexes, such as high-frequency power or band of heart rate variability as determined by spectral analysis, showed a significant day-by-treatment interaction (p < 0.005), whereas the CPAP- treated group had significantly more parasympathetic activity after 1 week of treatment. For the hemodynamic measures (stroke volume [SV], cardiac output, and systemic vascular resistance [SVR]), there were significant treatment-by-study day-by-test-period interactions (p < 0.01). SV and cardiac output increased across days, and SVR decreased in the CPAP-treated patients. These results indicate that CPAP normalizes contractility, increases cardiac vagal tone, and changes hemodynamic regulation from being resistance dominated to being cardiac dominated. Thus, after 1 week of treatment with CPAP, many of the indicators of poor cardiac functioning in apnea patients are improved.