Positive Pressure Devices Research Articles

The Role of OSA on Metabolic Disorders

Obstructive Sleep Apnea (OSAS) is a frequent disorder in the general population, and even more so among diabetics, with incidence values ranging from 17[1] to 48% [2], although these figures are probably an underestimation. The disorder has been always considered a boring affection and easily dismissed. Patients themselves often omit mentioning this affliction to the doctor. Only in the extreme cases the Continuous Positive Air Pressure device (CPAP) is used, with scant results, mostly due to noncompliance. Surgical correction of the upper airway abnormalities is at best only partially effective.

Home Ventilation Therapy in Obstructive Sleep Apnea–Hypopnea Syndrome

Obstructive sleep apnea–hypopnea is a highly prevalent disease that is often underdiagnosed at present. It has a significant economic and social welfare impact, accounting for a large part of the resources assigned to home respiratory therapies. As part of the 2014 SEPAR Year of the Chronic Patient and Domiciliary Respiratory Care sponsored by the Spanish Society of Pulmonology and Thoracic Surgery, this article reviews the most recent publications on the indications and controversial issues in the treatment of sleep apnea, the latest evidence for indication of various positive pressure devices, and adjustment modes, ranging from the use of empirical formulae or mathematical estimations to modern auto-CPAP equipment, while not forgetting the gold standard of manual titration. Emphasis is placed on the need for monitoring required by patients to ensure treatment adherence and compliance. Finally, other therapies that are not the object of this article are briefly reviewed.

Terapias ventilatorias domiciliarias en el síndrome de apnea-hipopnea del sueño

Obstructive sleep apnea-hypopnea is a highly prevalent disease that is often underdiagnosed at present. It has a significant economic and social welfare impact, accounting for a large part of the resources assigned to home respiratory therapies. As part of the 2014 SEPAR Year of the Chronic Patient and Domiciliary Respiratory Care sponsored by the Spanish Society of Pulmonology and Thoracic Surgery, this article reviews the most recent publications on the indications and controversial issues in the treatment of sleep apnea, the latest evidence for indication of various positive pressure devices, and adjustment modes, ranging from the use of empirical formulae or mathematical estimations to modern auto-CPAP equipment, while not forgetting the gold standard of manual titration. Emphasis is placed on the need for monitoring required by patients to ensure treatment adherence and compliance. Finally, other therapies that are not the object of this article are briefly reviewed.

A New Positive-Pressure Device for Nasal Foreign Body Removal

Nasal foreign bodies (FBs) are common causes of pediatric emergency consultations. The different methods for removing nasal FBs have varying levels of efficacy. The aim of this study was to evaluate the safety and efficacy of a new device for nasal FB removal in children. A nasal occlusion device that uses modulated positive pressure to remove FBs was evaluated in a series of 18 patients ranging in age from 1 to 8 years diagnosed with a nasal FB during a period of 7 months. The device successfully removed FBs in 17 (94.4%) of the 18 patients. In 12 of the cases (66.7%), the FB was removed during the first attempt. None of the patients had complications or sequelae at the time of removal or at the follow-up visit. The nasal occlusion device used in this study was found to be a promising, safe, effective, and easy to use tool for FB removal in a pediatric emergency room setting.

Acute effects of autoadjusting and fixed continuous positive airway pressure treatments on cardiorespiratory coupling in obese patients with obstructive sleep apnea

BackgroundTreatment with positive airway pressure devices improved signs and symptoms of obstructive sleep apnea syndrome (OSA); however, auto-adjusting positive pressure (APAP) device was not as effective as continuous positive airway pressure (CPAP) in reducing arterial blood pressure and insulin resistance. The role played by autonomic cardiac regulation remains to be clarified.We aimed to test the effects of CPAP and APAP on autonomic regulation and cardiorespiratory coupling during sleep. MethodsWe retrospectively analyzed full-night polysomnographic studies. 19 patients newly diagnosed with severe OSA (AHI>30) and 7 obese subjects without OSA (CON) were enrolled. Each OSA subject was assigned to CPAP or APAP treatment and underwent a sleep study after 1week of treatment. Spectral and cross-spectral analyses of heart rate variability (HRV) and respiration were performed to assess autonomic profile and coherence (K2) between respiration and HF oscillation during sleep in CPAP, APAP and CON groups. ResultsIn CPAP and CON, LFnu and LF/HF, markers of sympathetic modulation, decreased from N2 to N3 and increased during REM sleep (p<0.001), while in APAP group, sympathetic modulation was significantly higher compared with those of CPAP and CON during all sleep stages. K2 values were lower in APAP compared with those in CPAP and CON. ConclusionAPAP treatment was characterized by a greater sympathetic activation and it was associated with a lower cardio-respiratory coupling compared with CPAP. This might account for the different effects on cardiovascular risk factors induced by the two treatments.

Sleep-disordered breathing in pregnancy

Sleep-disordered breathing (SDB) during pregnancy has recently gained medical interest due to its consequences on maternal health and fetal outcome. In fact, although epidemiologic data are still scanty, several reports indicate that snoring and obstructive sleep apnea (OSA) during pregnancy are commonly associated with maternal hypertension, morbidly increased body mass index (BMI), diabetes mellitus and, at child birth, are correlated with an increased percentage of C-sections, preterm births with infants small for gestational age (SGA). OSA is an eminently treatable condition by means of assisted nocturnal ventilation with continuous positive air pressure (CPAP) devices. Diagnosis and treatment of this potential pregnancy complication should be thus more aggressively pursued in order to avoid harmful consequences to both mother and child.

Fluid shifts during running with body weight unloading by LBPP

At any given running speed, weight support with a lower body positive pressure (LBPP) device (i.e. Alter‐G treadmill) reduces VO2. We tested the hypothesis that mild LBPP would alter plasma volume (PV) shifts during exercise. Maximal aerobic capacity (VO2max) was determined in 8 male subjects at 100% and 80% (13.5 ± 0.1 mmHg LBPP) body weight loading at 0% grade. VO2, heart rate (HR), mean arterial blood pressure (MAP) and changes in Hct, [Hb], and total protein ([TP]) were determined on separate days in a randomized crossover design. Venous blood samples (5 cc) were taken at rest and at 5, 6, 7, 7.5, 8.0, and 8.5, 9.0 mph (0% grade) during each 3 min stage. Changes in plasma volume were calculated from changes in Hct and [Hb]. VO2max was similar for both BW loading trials and averaged about 52.5 ± 0.9 ml O2•min−1•kg−1 BW. The energy cost of running at 9 mph (42.3 ± 1.7 ml O2•min−1•kg−1 BW ) was reduced by 12% at 80% body weight (p&lt;0.05). During running at 80% BW HR was reduced compared to 100% BW running (p&lt;0.05) however the MAP response was similar. During exercise the reduction in PV, at any given VO2 was larger at 80% BW compared to 100% BW running (p&lt;0.001). At any give energy expenditure exercise with mild LBPP produced a greater shift of fluid out of the vascular space. It is interesting that 80% BW running resulted in a lower HR despite the larger reduction in PV. The impact of mild LBPP on venous return must counteract the role of reduced PV on stroke volume, thereby supporting a lower exercise HR.

Topical therapy in the management of chronic rhinosinusitis

A comprehensive literature review was conducted to evaluate the efficacy of various topical therapies of chronic rhinosinusitis (CRS): saline, antibiotics, corticosteroids, and antifungals. Emerging new studies can provide the necessary amendments to improve the treatment for CRS. Saline was more effective in treating CRS when administered with increased tonicity or through large volume, low positive pressure devices. Contamination rates of irrigation bottles were insufficient to outweigh the benefits of saline. Corticosteroids were effective in treating CRS with or without nasal polyps and reducing the chance of repeat endoscopic sinus surgery with manageable adverse effects and minimal systemic absorption. Antibiotics improved the quality of life of CRS patients, especially when it was culture directed or administered through a nebulizer in low-level studies. However, high-level studies showed antibiotics performed similarly to saline with additional risk of systemic absorption. Topical antifungal therapy did not demonstrate efficacy in CRS. In conclusion, topical saline and corticosteroids should be considered as the first line of therapy; hypertonic saline is recommended over isotonic solution if side effects are well tolerated. Additional studies are required to evaluate the efficacy of topical antibiotics with improved delivery methods. Also, to accurately assess the systemic absorption risk of topical corticosteroids and antibiotics, currently utilized measures need to be modified.

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Out-of-Hospital Noninvasive Ventilation: Epidemiology, Technology and Equipment

Noninvasive ventilation has been utilized successfully in the pre- and out-of-hospital settings for a variety of disorders, including respiratory distress syndrome in neonates, neurologic and pulmonary diseases in infants and children, and heart failure as well as chronic obstructive pulmonary disease in adults. A variety of interfaces as well as mechanical positive pressure devices have been used: simple continuous positive airway pressure devices are available which do not require sophisticated equipment, while a broad spectrum of ventilators have been used to provide bilevel positive airway pressure. Extensive training of transport teams may be important, particularly when utilizing bilevel positive airway pressure in infants and children.

Artificial lung as an alternative to mechanical ventilation in COPD exacerbation

To the Editors: Acute exacerbation of chronic obstructive pulmonary disease (COPD) is commonly treated with different kinds of noninvasive positive pressure devices, ranging from helmet or face-mask continuous positive airway pressure (CPAP) to noninvasive pressure support ventilation (NPPV), or Bi-PAP [1]. The use of positive end-expiratory pressure (PEEP) and NPPV often results in the successful treatment of COPD patients with respiratory distress [1, 2]. If, despite maximal medical management, respiratory distress and gas exchange deteriorate with increasing tachypnoea and acidosis, and with altered level of consciousness, then tracheal intubation and mechanical ventilation (MV) become mandatory [3]. However, tracheal intubation and MV have several detrimental side-effects that may concur to determine the high morbidity and mortality reported in COPD patients requiring them [3, 4]. Indeed, the increase in airway resistance, the prolonged time required for lung emptying and the resulting dynamic hyperinflation, named auto-PEEP [4], are the most important physiological alterations during COPD exacerbation. In this condition, the application of MV could increase lung hyperinflation and lead to barotrauma and circulatory failure [4, 5]. Furthermore, tracheal intubation is usually associated with the need for sedation. The side-effects of intubation, sedation and MV may initiate a vicious circle, often resulting in a very difficult or impossible weaning. In this report, we describe a patient with severe exacerbation of COPD, in whom after failure of noninvasive ventilation, we decided to treat the respiratory acidosis, tachypnoea and ventilatory fatigue by removing CO2 with an artificial lung. This avoided the need for tracheal intubation and MV, leaving the patient in spontaneous breathing. In September 2010, a 72-yr-old, female heavy …

P68 A study to investigate the clinical use and outcomes of EZPAP positive pressure device

IntroductionThe EZPAP is a positive pressure hand held device that amplifies an input flow of either air or oxygen approximately four times and so positive pressure is maintained throughout the...

The Mechanical Ventilator: Past, Present, and Future

The use of ventilatory assistance can be traced back to biblical times. However, mechanical ventilators, in the form of negative-pressure ventilation, first appeared in the early 1800s. Positive-pressure devices started to become available around 1900 and today's typical intensive care unit (ICU) ventilator did not begin to be developed until the 1940s. From the original 1940s ventilators until today, 4 distinct generations of ICU ventilators have existed, each with features different from that of the previous generation. All of the advancements in ICU ventilator design over these generations provide the basis for speculation on the future. ICU ventilators of the future will be able to integrate electronically with other bedside technology; they will be able to effectively ventilate all patients in all settings, invasively and noninvasively; ventilator management protocols will be incorporated into the basic operation of the ventilator; organized information will be presented instead of rows of unrelated data; alarm systems will be smart; closed-loop control will be present on most aspects of ventilatory support; and decision support will be available. The key term that will be used to identify these future ventilators will be smart!

What is this thing called somnolence?

In 1929, Cole Porter composed, for a musical comedy, a song called “What Is This Thing Called Love?”, which became a great classic in jazz music [1]. The musical comedy had a suggestive title, very appealing for modern pneumologists: Wake Up and Dream . For many people suffering from obstructive sleep apnoea, we are able nowadays to help them to wake up refreshed, out of dreams or nightmares, and able to face the new day fully awake, fit to burst [2]. This is the usual result of sleeping with a mask connected to a continuous positive pressure device [3]. However, a small number of patients compliant to continuous positive airway pressure (CPAP) therapy, using it every night and all night, remain abnormally sleepy. They declare persistent severe somnolence and fatigue [4, 5]. In this issue of the European Respiratory Journal , Vernet et al. [6] present the results of an extraordinary effort to dissect, define and identify what causes somnolence in these patients. They studied 20 patients with CPAP-treated obstructive sleep apnoea and persistent complains of daytime sleepiness and fatigue, and compared them with 20 other well-matched patients that had no residual sleepiness, and to 20 matched normal subjects. They made every possible effort to exclude other known causes of daytime sleepiness and fatigue, from narcolepsy to restless leg syndrome, depression, behavioural sleep restriction, chronic use of sedative drugs, alcoholism, night shift work, and neurological and psychiatric diseases. Once they were sure that these patients had only …

Treatment experience of people with obstructive sleep apnoea seeking continuous positive airways pressure device provision through community pharmacies – a role for pharmacists?

OBJECTIVES This study aimed to explore the unique experiences of people with obstructive sleep apnoea (OSA) who source their treatment through community pharmacies. METHODS A qualitative study employing the phenomenological approach was used. In-depth semi-structured interviews with a purposive convenience sample of 20 participants were conducted. Twenty participants were recruited from community pharmacies offering continuous positive airways pressure (CPAP) device provision and a teaching hospital in Sydney, Australia. Interviews were digitally recorded and transcribed verbatim, coded using Nvivo8 software and analysed based on the 'framework' method. KEY FINDINGS The quality and delivery of information at diagnosis was reported to have been inappropriate for participants' personal needs. Many barriers emerged in regards to CPAP use, consistent with current literature. Participants' self-reported individual styles, coping practices and health beliefs appeared to be the most influential factors in CPAP uptake and adherence, regardless of mechanical advancements and environmental support. High satisfaction was expressed with CPAP obtainment from pharmacy services listing convenience and good service as notable characteristics. CONCLUSIONS Community pharmacies have the potential to increase OSA awareness and improve optimal usage of CPAP. Psychosocial based models of adherence intervention could potentially be implemented through CPAP providers, including the community pharmacy, to address some of these factors which impede CPAP adherence.

Randomised controlled trial of auto-adjusting positive airway pressure in morbidly obese patients requiring high therapeutic pressure delivery

Auto-adjusting positive airway pressure (APAP) devices are being increasingly used to treat obstructive sleep apnoea (OSA). Anecdotal encounters of obese patients requiring high therapeutic pressure whose OSA was inadequately controlled by APAP led to this study aiming to compare the effectiveness of continuous positive airway pressure (CPAP) and APAP (S8 Autoset II(®) , ResMed, NSW, Australia) in a randomised, single-blinded crossover trial. Twelve morbidly obese patients with severe OSA [mean±SD apnoea-hypopnoea index (AHI) 75.8±32.7, body mass index 49.9±5.2 kg m(-2) , mean pressure 16.4 cmH(2)O] were consecutively recruited, and received CPAP or APAP in random order for six nights at home, separated by a four-night washout. Polysomnographic (PSG) indices of OSA were recorded at baseline and following each treatment arm. Both therapies substantially reduced the AHI (APAP 9.8±9.5 and CPAP 7.3±6.6 events h(-1) ; P=0.35), but residual PSG measures of disease (AHI >5) were common. APAP delivered a significantly lower 95th percentile pressure averaged over the home-use arm than CPAP (14.2±2.7 and 16.1±1.8 cmH(2)O, respectively, P=0.02). The machine-scored AHI significantly overestimated the level of residual disease compared with the laboratory-scored AHI (using Chicago criteria); however, when the machine-scored AHI was ≤5 and ≤10 this was always confirmed by the PSG data. In morbidly obese OSA patients without significant co-morbid disease requiring high therapeutic pressure, our data provide support for the use of either APAP or manually titrated CPAP. We recommend objective assessment by sleep study if the S8 Autoset II indicates a high level of residual disease.

Critérios diagnósticos e tratamento dos distúrbios respiratórios do sono: SAOS

In this chapter, the principal approaches to the diagnosis and treatment of patients with obstructive sleep apnea syndrome (OSAS) are presented. The diagnosis should be carried out by the taking of a thorough clinical history and by physical examination. For diagnostic confirmation, it is necessary to perform supervised overnight polysomnography. For patients in whom clinical suspicion is high, a simplified home study can be an alternative. The treatment of OSAS requires general measures and the use of positive pressure devices. In moderate and severe cases, CPAP is the method of choice, whereas oral appliances can be used in mild cases. Surgical procedures are recommended when anatomical alterations are evident or as an auxiliary method in combination with other types of treatment.

Metabolic and Biomechanical Effects of Velocity and Weight Support Using a Lower-Body Positive Pressure Device During Walking

Grabowski AM. Metabolic and biomechanical effects of velocity and weight support using a lower-body positive pressure device during walking. Objectives To determine how changes in velocity and weight support affect metabolic power and ground reaction forces (GRFs) during walking using a lower-body positive pressure (LBPP) device. To find specific velocity and weight combinations that require similar aerobic demands but different peak GRFs. Design Repeated measures. Setting University research laboratory. Participants Healthy volunteer subjects (N=10). Interventions Subjects walked 1.00, 1.25, and 1.50m/s on a force-measuring treadmill at normal weight (1.0 body weight [BW]) and at several fractions of BW (.25, .50, .75, .85 BW). The treadmill was enclosed within an LBPP apparatus that supported BW. Main Outcome Measures Metabolic power, GRFs, and stride kinematics. Results At faster velocities, peak GRFs and metabolic demands were greater. In contrast, walking at lower fractions of BW attenuated peak GRFs and reduced metabolic demand compared with normal weight walking. Many combinations of velocity and BW resulted in similar aerobic demands, yet walking faster with weight support lowered peak GRFs compared with normal weight walking. Conclusions Manipulating velocity and weight using an LBPP device during treadmill walking can reduce force yet maintain cardiorespiratory demand. Thus, LBPP treadmill training devices could be highly effective for rehabilitation after orthopedic injury and/or orthopedic procedures.

Sleep dysfunction in heart failure

Chronic congestive heart failure is a highly prevalent and progressive disorder associated with excess morbidity and mortality; it has huge economic impact. Left heart failure may be systolic or may occur as isolated diastolic dysfunction. The diastolic form predominates in older people. Sleep disorders are frequent in both types. Most systematic studies have been performed in patients with systolic heart failure. Prospective studies show the presence of obstructive and central sleep apnea, periodic limb movements, and significant alterations in sleep architecture, characterized by poor efficiency, excess stage 1 and arousals, and lack of deep sleep. Both obstructive sleep apnea and central sleep apnea occur in patients with heart failure and have been shown to be associated with excess mortality. Obstructive sleep apnea is best treated with continuous positive airway pressure (CPAP) devices. Central sleep apnea is also best treated with CPAP, but only about 50% of the patients are considered responders. Survival improves when heart failure patients are effectively treated with CPAP for both central and obstructive sleep apnea. A new positive airway pressure device, a pressure support servo-ventilator, is the next best choice for heart failure patients whose central sleep apnea does not respond to CPAP. Nocturnal oxygen should be used for patients whose central sleep apnea does not respond to positive pressure devices. Both periodic limb movements and insomnia could have adverse hemodynamic consequences for the failing heart. There are no guidelines or long-term studies regarding treatment of these conditions in heart failure. For restless legs syndrome with or without periodic limb movements, pramipexole and ropinirole have been approved. Treatment of insomnia comorbid with heart failure depends on the cause. In the absence of any known cause, a trial of ramelteon is the first choice.

A Simple Removable Custom Made Mandibular Advancement Device Fabricated for an Elderly Lady Suffering from Obstructive Sleep Apnea – A Case Report

Nearly every practitioner in dentistry, no matter what his or her specialty or special interest, may have a potential role in the management of patients with a sleep disorder, particularly snoring and sleep apnoea. Every dentist as a practitioner in the healthcare field should be able to assist the patient identified with a potential sleep disorder by making recommendations, referrals or participating in overall management. Many dentists are not familiar with sleep medicine, its magnitude, and prevalence of sleep disorders. This case report reflects how a low cost custom made mandibular repositioning appliance has helped an obese severe obstructive sleep apnea patient, non-affordable for continuous positive pressure device in getting relieved of her symptoms and improved her quality of life by a better night's rest.