Treatment-emergent Central Sleep Apnea Research Articles

Treatment-Emergent Central Sleep Apnea (Complex Sleep Apnea)

Treatment-emergent central sleep apnea (TECSA) is a distinct form of sleep-disordered breathing characterized by the development of central sleep apnea during the initiation of positive airway pressure (PAP) therapy in patients with obstructive sleep apnea. The exact mechanisms of TECSA are not clearly known; however, several theories have been proposed. Usually, TECSA is transient and self-limited, and disappears after continued PAP use. Nevertheless, patients with persistent TECSA have lower adherence to PAP therapy and are more likely to terminate therapy. Close follow up is necessary to assure that the emergent central events disappear with continued therapy. In patients with persistent TECSA, more advanced algorithms such as adaptive servo-ventilation have been shown to be very effective. In this brief review, we summarize the definition, prevalence, predictors, pathophysiology, and treatment approaches of TECSA.

Trajectories of Emergent Central Sleep Apnea During CPAP Therapy

BackgroundThe emergence of central sleep apnea (CSA) during positive airway pressure (PAP) therapy has been observed clinically in approximately 10% of obstructive sleep apnea titration studies. This study assessed a PAP database to investigate trajectories of treatment-emergent CSA during continuous PAP (CPAP) therapy.MethodsU.S. telemonitoring device data were analyzed for the presence/absence of emergent CSA at baseline (week 1) and week 13. Defined groups were as follows: obstructive sleep apnea (average central apnea index [CAI] < 5/h in week 1, < 5/h in week 13); transient CSA (CAI ≥ 5/h in week 1, < 5/h in week 13); persistent CSA (CAI ≥ 5/h in week 1, ≥ 5/h in week 13); emergent CSA (CAI < 5/h in week 1, ≥ 5/h in week 13).ResultsPatients (133,006) used CPAP for ≥ 90 days and had ≥ 1 day with use of ≥ 1 h in week 1 and week 13. The proportion of patients with CSA in week 1 or week 13 was 3.5%; of these, CSA was transient, persistent, or emergent in 55.1%, 25.2%, and 19.7%, respectively. Patients with vs without treatment-emergent CSA were older, had higher residual apnea-hypopnea index and CAI at week 13, and more leaks (all P < .001). Patients with any treatment-emergent CSA were at higher risk of therapy termination vs those who did not develop CSA (all P < .001).ConclusionsOur study identified a variety of CSA trajectories during CPAP therapy, identifying several different clinical phenotypes. Identification of treatment-emergent CSA by telemonitoring could facilitate early intervention to reduce the risk of therapy discontinuation and shift to more efficient ventilator modalities.

0861 CHARACTERIZING TREATMENT EMERGENT CENTRAL SLEEP APNEA IN CHILDREN

Treatment emergent central sleep apnea (TECSA) is a sleep disorder in which central apnea occurs once positive airway pressure has been applied to resolve obstructive apneas. TECSA has not been characterized in children. The purpose of this study is to determine the prevalence of TECSA in children and identify characteristics of children who develop TECSA. This retrospective study included children aged 0–18 started on long-term non-invasive ventilation who had both diagnostic and treatment polysomnography. The criteria for TECSA included: obstructive apnea-hypopnea Index (OAHI) ≥5 during the diagnostic study; improvement in OAHI on the treatment study; central apnea index (CAI) remaining the same or worsening from diagnostic to treatment study; and central apnea Index (CAI) ≥5 and accounting for ≥50% of the apnea-hypopnea index (AHI) during the treatment study. Each child with TECSA was matched to three children of similar age and sleep study date to construct a non-TECSA comparison group. Data collection included clinical characteristics in addition to the diagnostic, first and subsequent treatment studies. Out of our population of 146 children, 13 were identified as having TECSA for a prevalence of 8.9%. During diagnostic studies, TECSA children had significantly higher OAHI and AHI than non-TECSA children (OAHI: 29.5 ± 25.1 events/h vs 16.0 ± 15.0 events/h, p<0.05; AHI: 33.4 ± 24.7 events/h vs 19.6 ± 17.3 events/h, p<0.05). During titration studies, CAI and AHI were significantly higher in TECSA children than matched controls (CAI: 22.6 ± 32.1 events/h vs 2.0 ± 3.7 events/h, p<0.001; AHI: 29.6 ± 10.0 events/h vs 7.7 ± 9.4 events/h,p<0.001). The mean airway pressure for treatment did not differ between TECSA and non-TECSA children (6.9 ± 1.8 mmHg vs 6.5 ± 1.8 mmHg, p=ns). Six TECSA children had follow-up treatment studies; in 4 children (67%) criteria for TECSA was not met at follow-up. The prevalence of TECSA in children is similar to what is reported in adults. Higher obstructive indices during diagnostic sleep studies may provide an early indicator for TECSA risk. TECSA may be a transient phenomenon as the majority of TECSA children did not meet the criteria for the disorder at follow-up. A prospective study would be helpful to further explore this finding. None

Whom are we treating with adaptive servo-ventilation? A clinical post hoc analysis

Recent evidence has shown that adaptive servo-ventilation (ASV) is contraindicated in patients with predominant central sleep apnea (CSA) and reduced left ventricular ejection fraction (LVEF ≤45%). The objective of this study was to assess the clinical usage of ASV in patients at the time-point of the release of a safety warning by type of SDB, breathing pattern and LVEF. Patients of a cardiac and a respirology sleep center, both in Germany, who received ASV therapy were contacted between May and October 2015. Retrospective analyses included diagnostic polysomnography, polysomnography with continuous positive airway pressure prior to ASV initiation and echocardiography. Treatment emergent CSA was diagnosed after an appropriate treatment period on CPAP. 285 patients receiving ASV therapy (91 in the cardiac and 194 in the respirology setting) underwent diagnostic polysomnography. 233 (82%) patients had severe SDB, 94 (33%) predominant CSA, and 185 (65%) periodic breathing. 20% (n=52) of patients had an LVEF of ≤45%. The most common indications for ASV were CSA in heart failure (41%) in the cardiac setting and treatment emergent CSA (80%) diagnosed after an appropriate period on CPAP in the respirology setting. The proportion of patients in whom ASV was contraindicated (CSA and LVEF ≤45%) was 16% in the cardiac setting and 9% in the respirology setting. Clinical usage of ASV changed for a small subgroup of patients after release of the SERVE-HF results. Nevertheless, ASV treatment should be monitored and evaluated with diligence in the reminder indications.

Incidence and influencing factors of continuous positive airway pressure treatment-emergent central sleep apnea in the patients with obstructive sleep apnea syndrome at high altitude

Objective: To investigate the incidence of treatment-emergent central sleep apnea (TE-CSA), the characteristics of demography and the influencing factors in patients with obstructive sleep apnea syndrome (OSAS) after initial continuous positive airway pressure (CPAP) titration at high altitude. Methods: Clinical data of 297 patients with OSAS which living in plateau areas (1 000 meters or more above sea level) were retrospectively analyzed in this study from January to December, 2015. All of these patients taken an overnight CPAP titration in the Sleep Medicine Center of First People's Hospital of Yunnan Province. They were classified as with TE-CSA group and non TE-CSA group according to the outcome of CPAP titration. Comparisons of demographic characteristic, parameters of polysomnography in CPAP titration night, lung function test and blood gas analysis were made between the two groups, respectively, and statistical analysis was carried. Results: The incidence of TE-CSA was 16.5% (49/297) after initial CPAP titration at high altitude, which was higher in male patients (18.2% vs 6.8%, P=0.061). The incidence of TE-CSA decreased with the increase of age and body mass index (BMI), and the decrease of resident altitude. Multivariate Logistic regression analysis showed that the resident altitude, mixed apnea index (MAI), forced expiratory volume in 1 second (FEV(1)) and forced vital capacity (FVC) ratio, functional residual capacity (RV) and total lung capacity (TLC) ratio were the main factors affecting the occurrence of TE-CSA. Among them, the increase of resident altitude and MAI were risk factors [OR=1.16(1.02, 1.32), 1.05(1.01, 1.09)]. The increase of FEV(1)/FVC and RV/TLC were protective factors [OR=0.94(0.89, 0.98), 0.94(0.88, 0.99)]. Conclusion: The incidence of TE-CSA is high at high altitude area, and the increase of resident altitude and MAI are the risk factors for TE-CSA.

Clinical predictors of central sleep apnea evoked by positive airway pressure titration

PurposeTreatment-emergent central sleep apnea (TECSA), also called complex apnea, occurs in 5%–15% of sleep apnea patients during positive airway pressure (PAP) therapy, but the clinical predictors are not well understood. The goal of this study was to explore possible predictors in a clinical sleep laboratory cohort, which may highlight those at risk during clinical management.MethodsWe retrospectively analyzed 728 patients who underwent PAP titration (n=422 split-night; n=306 two-night). Demographics and self-reported medical comorbidities, medications, and behaviors as well as standard physiological parameters from the polysomnography (PSG) data were analyzed. We used regression analysis to assess predictors of binary presence or absence of central apnea index (CAI) ≥5 during split-night PSG (SN-PSG) versus full-night PSG (FN-PSG) titrations.ResultsCAI ≥5 was present in 24.2% of SN-PSG and 11.4% of FN-PSG patients during titration. Male sex, maximum continuous positive airway pressure, and use of bilevel positive airway pressure were predictors of TECSA, and rapid eye movement dominance was a negative predictor, for both SN-PSG and FN-PSG patients. Self-reported narcotics were a positive predictor of TECSA, and the time spent in stage N2 sleep was a negative predictor only for SN-PSG patients. Self-reported history of stroke and the CAI during the diagnostic recording predicted TECSA only for FN-PSG patients.ConclusionClinical predictors of treatment-evoked central apnea spanned demographic, medical history, sleep physiology, and titration factors. Improved predictive models may be increasingly important as diagnostic and therapeutic modalities move away from the laboratory setting, even as PSG remains the gold standard for characterizing primary central apnea and TECSA.

A systematic review on prevalence and risk factors associated with treatment- emergent central sleep apnea.

INTRODUCTION:Treatment-emergent central sleep apnea (TECSA) is the appearance of central apneas and hypopneas after significant resolution of the obstructive events has been attained using positive airway pressure (PAP) therapy. The aim of the study was to determine the prevalence of TECSA and to understand what factors are associated with its development.METHODS:PubMed, MEDLINE, Scopus, Web of Science and Cochran Library databases were searched with Mesh headings to locate studies linking TECSA and obstructive sleep apnea (OSA).RESULTS:Nine studies were identified that reported the prevalence of TECSA ranging from 5.0% to 20.3%. Prevalence of TECSA for studies using only full night titration was between 5.0% and 12.1% where as it was between 6.5% and 20.3% for studies using split-night polysomnogram. The mean effective continuous PAP (CPAP) setting varied between 7.5 cm and 15.2 cm of water for patients in TECSA group and between 7.4 cm and 13.6 cm of water for the group without TECSA.CONCLUSIONS:The aggregate point prevalence of TECSA is about 8% with the estimated range varying from 5% to 20% in patients with untreated OSA. The prevalence tends to be higher for split-night studies compared to full night titration studies. TECSA can occur at any CPAP setting although extremely high CPAP settings could increase the likelihood. Male gender, higher baseline apnea-hypopnea index, and central apnea index at the time of diagnostic study could be associated with the development of TECSA at a subsequent titration study.

Clinical impact of adaptive servoventilation compared to other ventilatory modes in patients with treatment-emergent sleep apnea, central sleep apnea and Cheyne–Stokes respiration

IntroductionAdaptive servoventilation is a recent ventilatory mode initially designed to treat Cheyne–Stokes respiration (CSR). Recently, the efficacy of ASV has been discussed for the treatment of central sleep apnea (CSA) and treatment-emergent central sleep apnea (treatment-emergent CSA) where other forms of traditional positive airway pressure (PAP) may be insufficient. ObjectivesTo compare the clinical impact of ASV with other forms of PAP in treating patients with treatment-emergent CSA, CSA and CSR. MethodsMedical data of all the patients who underwent polysomnography (PSG) with ASV titration were evaluated. The patients were divided into two groups according to the mode of ventilation reimbursed: ASV and PAP (AutoCPAP/CPAP/BIPAP). All patients had a minimal follow-up of 6 months. Both groups were compared in terms of symptoms, apnea hypopnea index, compliance, cardiac function and cardiovascular events. ResultsASV titration was performed in 33 patients (30M/3F) with a mean age of 69±8 years. The majority (58%) present a treatment-emergent SA and 42% a CSA and or CSR. The median initial diagnostic AHI was 46±22events/h.After the initial diagnosis, 28 patients were treated with PAP and 5 with servoventilation. All of the patients treated with PAP were posteriorly submitted to PSG and ASV titration because of suboptimal response to PAP. Despite a clear indication for ASV, due to differences in reimbursement, 15 patients continued treatment with PAP (12 with AutoCPAP, 1 with BIPAP and 2 with CPAP) and 16 changed to ASV. Two patients were lost in follow-up.In both groups, most of patients present a treatment-emergent SA (53% in ASV group vs. 67% in PAP group) or a CSA/CSR (29.4% in ASV group vs. 20% in PAP). After ASV titration, the mean follow-up was 25±14 months. Both groups (ASV vs. PAP) were similar in terms of compliance (77±23% vs.88±14%) and in terms of Epworth sleepiness scale score (6±5 vs. 7±5). There was a statistical difference in terms of residual AHI: mean AHI was 4±3 in ASV group and 9±3 in PAP group (P=0.005). We found no differences in terms of left ventricular fractional shortening (ASV 33±10% vs. PAP 32±10%). Although no difference was observed between the 2 groups in terms of non-fatal cardiovascular events (3 events in each group), 2 fatal cardiovascular events occurred in the PAP group (sudden death). ConclusionsThese data confirm that ASV is an efficient treatment in patients with treatment-emergent CSA, CSA/CSR significantly decreasing residual AHI. In both groups, compliance rate was high and sleepiness improved. It is relevant that the 2 patients who died of sudden death were treated with PAP.

Complex Sleep Apnea

Complex sleep apnea entails the combination of obstructive and central sleep apnea during the same polysomnographic study. Treatment-emergent central sleep apnea during administration of positive airway pressure for obstructive sleep apnea is the most common form of complex sleep apnea. Predisposing factors for complex sleep apnea are baseline hypocapnia and heart disease with a long circulation time and low cardiac output, or the concurrent use of opioids. In most cases of treatment-emergent complex sleep apnea without cardiovascular comorbidity or opioid use, the central component may resolve with use of continuous positive airway pressure sufficient to eliminate the obstructive component. Effective treatment of persistent complex sleep apnea can be achieved with the use of adaptive servoventilation.

Adapting Our Approach to Treatment-Emergent Central Sleep Apnea

Adapting Our Approach to Treatment-Emergent Central Sleep Apnea

The Emergence of Central Sleep Apnea after Surgical Relief of Nasal Obstruction in Obstructive Sleep Apnea

By the current definition, complex sleep apnea (CompSA) refers to the emergence of central sleep apnea (CSA) during the treatment of obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP). However, new-onset CSA has been described with use of other treatments for OSA, including tracheostomy, maxillofacial surgery, and mandibular advancement device. We present a patient with CSA beginning after endoscopic sinus and nasal surgery for nasal obstruction in the setting of mild OSA. This case highlights the importance of non-PAP mechanisms in the pathogenesis of CompSA.

Acetazolamide as an Adjunct to CPAP Treatment: A Case of Complex Sleep Apnea in a Patient on Long-Acting Opioid Therapy

A 41-year-old white woman on long-acting opioid therapy was diagnosed with moderate obstructive sleep apnea. On initiation of continuous positive airway pressure (CPAP), she manifested severe central apnea that was unresponsive to supplemental oxygen and interfered with CPAP titration. Acetazolamide, 250 mg, nightly at bedtime was initiated, and CPAP titration was repeated. On acetazolamide, optimal CPAP pressure was obtained with no manifestation of clinically significant central respiratory disturbance. This case suggests that acetazolamide may be an effective adjunct to positive airway pressure therapy in patients on long-acting opioids. A need exists for examination of acetazolamide in this capacity.