Clinical impact of adaptive servoventilation compared to other ventilatory modes in patients with treatment-emergent sleep apnea, central sleep apnea and Cheyne–Stokes respiration
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Is adaptive servoventilation really the answer?”" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:1 [ "paginaInicial" => "64" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "S. Correia, V. Martins, L. Sousa, J. Moita, F. Teixeira, J.M. dos Santos" "autores" => array:6 [ 0 => array:2 [ "nombre" => "S." "apellidos" => "Correia" ] 1 => array:2 [ "nombre" => "V." "apellidos" => "Martins" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Sousa" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Moita" ] 4 => array:2 [ "nombre" => "F." "apellidos" => "Teixeira" ] 5 => array:2 [ "nombre" => "J.M." "apellidos" => "dos Santos" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173511515001852?idApp=UINPBA00004E" "url" => "/21735115/0000002200000001/v1_201602030050/S2173511515001852/v1_201602030050/en/main.assets" ] ] "en" => array:14 [ "idiomaDefecto" => true "titulo" => "Clinical impact of adaptive servoventilation compared to other ventilatory modes in patients with treatment-emergent sleep apnea, central sleep apnea and Cheyne–Stokes respiration" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "132" "paginaFinal" => "137" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Sílvia Correia, Vitória Martins, Liliana Sousa, Joaquim Moita, Fátima Teixeira, José Moutinho dos Santos" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Sílvia" "apellidos" => "Correia" "email" => array:1 [ 0 => "silvia_s_correia@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor1" ] ] ] 1 => array:3 [ "nombre" => "Vitória" "apellidos" => "Martins" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] 2 => array:3 [ "nombre" => "Liliana" "apellidos" => "Sousa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] ] ] 3 => array:3 [ "nombre" => "Joaquim" "apellidos" => "Moita" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] 4 => array:3 [ "nombre" => "Fátima" "apellidos" => "Teixeira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] 5 => array:3 [ "nombre" => "José Moutinho" "apellidos" => "dos Santos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Pneumology Department, ULS-Guarda, Sousa Martins Hospital, Guarda, Portugal" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Pneumology Department, HG-CHUC, Sleep Medicine Center, Coimbra, Portugal" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] 2 => array:3 [ "entidad" => "Neurophysiology Department, HG-CHUC, Sleep Medicine Center, Coimbra, Portugal" "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor1" "etiqueta" => "<span class="elsevierStyleSup">*</span>" "correspondencia" => "Corresponding author. silvia_s_correia@hotmail.com" ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig1" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "descripcion" => array:1 [ "en" => "Efficacy of adaptive servoventilation (ASV) on sleepiness." ] ] ] "textoCompleto" => "<a name="sec0005" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Introduction</span><p class="elsevierStylePara">Central sleep apnea is characterized by a lack of drive during sleep resulting in insufficient or absent ventilation and compromised gas exchange. The lack of respiratory efforts during cessation of airflow may lead to frequent nighttime awakenings, with consequent excessive daytime sleepiness and increased risk of adverse cardiovascular outcomes.<a href="#bib21" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">1</span></a></p><p class="elsevierStylePara">Cheyne–Stokes respiration (CSR) is a disorder characterized by recurrent central apneas during sleep alternating with a crescendo-decrescendo pattern of tidal volume. It is observed in patients with congestive heart failure, usually during stages 1 and 2 non-REM sleep when ventilation is under chemical-metabolic control.<a href="#bib22" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">, </span><a href="#bib23" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a></p><p class="elsevierStylePara">In recent years, sleep physicians have recognized that some patients with obstructive sleep apnea develop central apneas or CSR after initial treatment with positive airway therapy. That sleep disorder is called treatment-emergent central sleep apnea. The significance and the prevalence of treatment-emergent SA is not clear; it ranges from 2.5% to 20%.<a href="#bib24" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">, </span><a href="#bib25" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">5</span></a><span class="elsevierStyleSup">, </span><a href="#bib26" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">, </span><a href="#bib27" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">7</span></a><span class="elsevierStyleSup">, </span><a href="#bib28" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">8</span></a><span class="elsevierStyleSup">, </span><a href="#bib29" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleSup">, </span><a href="#bib30" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">10</span></a> There is some controversy around the optimal treatment of CSA syndrome and treatment-emergent central sleep apnea.</p><p class="elsevierStylePara">Adaptive servoventilation is a recent ventilatory mode, able to provide a dynamic adjustment of inspiratory pressure support. ASV continuously calculates a target minute ventilation, breath-by-breath, increasing or decreasing the pressure support in order to avoid transient episodes of central hypopnea/apnea after hyperventilation and associated hypocapnia.</p><p class="elsevierStylePara">The first commercial ASV devices became available in 2006. The device used for PSG in this study is AutoSet CS<span class="elsevierStyleSup">®</span>. The device provides a fixed end-expiratory pressure adjusted to treat obstructive events and a respiratory frequency back-up rate. The inspiratory pressure is adjusted by the device in order to obtain a calculated target ventilation (90% of the patient's recent average ventilation) of a running 3 min reference period.</p><p class="elsevierStylePara">The present study is a retrospective case-series comparison of the efficacy of traditional non-invasive positive pressure ventilation (PAP) and ASV in patients with diagnosis of treatment-emergent central sleep apnea, central sleep apnea and or Cheyne–Stokes respiration.</p><a name="sec0010" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Methods</span><a name="sec0015" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Patients</span><p class="elsevierStylePara">We identified all the patients referred to ASV titration at our Sleep Medicine Center. Most of the patients had previously undergone an unsuccessful PAP trial.</p><a name="sec0020" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Definitions</span><p class="elsevierStylePara">The ASV titration was done by split-night PSG (SomnoStar<span class="elsevierStyleSup">®</span> Sleep System). Sleep stage scoring was performed according to standard criteria of the <span class="elsevierStyleItalic">American Association Sleep Medicine (2007)</span>. An apnea was defined as ≥90% airflow reduction for ≥10 s, and a hypopnea was defined as ≥30% reduction in airflow for ≥10 s accompanied by ≥3% desaturation from baseline. An arousal was defined as ≥3-s increase in EEG frequency following ≥10 s of stable sleep, accompanied by an increase in submentalis EMG activity for ≥1 s during REM sleep. The AHI was calculated as the number of apneas and hypopneas per hour of sleep. The arousal index was calculated as the number of arousals per hour of sleep. Obstructive sleep apnea syndrome was diagnosed if RDI was ≥5 events and the patient was symptomatic (daytime sleepiness, nocturnal gasping or choking, loud snoring with description of breathing interruptions) or if RDI was >15 even if patient was asymptomatic. CSA was diagnosed if the number of central apnea per hour was ≥5 and at least 50% of the total AHI was central in origin. Treatment-emergent SA was diagnosed if CPAP titration eliminated obstructive events but the residual central apnea index (CAI) was ≥5 or the CSR pattern became predominant.</p><a name="sec0025" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Study design</span><p class="elsevierStylePara">After the baseline sleep study, patients diagnosed with treatment-emergent CSA, CSA or CSR were submitted to a second PSG (SomnoStar<span class="elsevierStyleSup">®</span> Sleep System) for ASV titration. Titration was performed online by the neurophysiologist technician in sleep laboratory. Medical charts were reviewed and demographic, clinical and polygraphic/polysomnographic data were extracted.</p><p class="elsevierStylePara">After PSG with ASV titration, the eligible subjects were allocated into 2 groups: patients who received flow-triggered ASV (BiPAP Auto SV Phillips and VPAP Adapt SV Resmed) and those who received PAP (AutoCPAP/CPAP/BIPAP) (REMStar Auto Philips and Auto Spirit S8/S9). Both groups had a minimal follow-up of 6 months. The selection of the ventilator mode was exclusively based on differences in reimbursement.</p><p class="elsevierStylePara">In the CPAP group, airway pressure was manually modulated from 6 cmH<span class="elsevierStyleInf">2</span>O to the effective pressure, with a maximum of 14 cmH<span class="elsevierStyleInf">2</span>O. The appropriate fixed pressure was chosen as the pressure abolishing or significantly decreasing both obstructive events (including apnea, hypopnea, and snoring) and CSR without arousal.</p><p class="elsevierStylePara">After a minimum time of 6 months, residual IAH, compliance, Epworth sleepiness scale, left ventricular shortening fraction and cardiovascular events were recorded. Residual AHI was given by the ventilator support device data.</p><a name="sec0030" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Statistical methods</span><p class="elsevierStylePara">Statistical analysis was performed using SPSS version 17.0 for Windows. All values are shown as the means SD, and categorical variables are expressed as numbers and percentages. The baseline characteristics were compared using Student's <span class="elsevierStyleItalic">t</span> test for continuous variables, whereas the Chi-square test or Fisher's exact test was used for categorical variables. Within- and between-group comparisons of measurements were carried out using paired and unpaired Student's <span class="elsevierStyleItalic">t</span> tests for normally distributed data, and the Wilcoxon-signed rank test for non-normally distributed data.</p><p class="elsevierStylePara">Values <0.05 were considered statistically significant.</p><a name="sec0035" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Results</span><a name="sec0040" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Demographics and clinical findings</span><p class="elsevierStylePara">Thirty-three patients were included: 30 men and 3 women with an average age of 68 ± 8 years.</p><p class="elsevierStylePara">Patient baseline characteristics before any positive pressure therapy are summarized in <a href="#t0005" class="elsevierStyleCrossRefs">Table 1</a>. Of the 33 patients submitted to ASV titration, 16 were allocated to ASV, 15 to the PAP and 2 patients were lost in follow-up. In PAP group, 12 patients were treated with AutoCPAP, 1 with BIPAP and 2 with CPAP.</p><p class="elsevierStylePara">Table 1. Patient baseline characteristics before any positive pressure therapy.</p><a name="t0005" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"></p><table><tr align="left"><td> </td><td>ASV group (<span class="elsevierStyleItalic">n</span> = 16)</td><td>PAP group (<span class="elsevierStyleItalic">n</span> = 15)</td><td><span class="elsevierStyleItalic">P</span> value</td></tr><tr align="left"><td colspan="4"><span class="elsevierStyleItalic">Demographic characteristics</span></td></tr><tr align="left"><td>Age (yr)</td><td>71 ± 6</td><td>66 ± 10</td><td>0.11</td></tr><tr align="left"><td>Body mass index (kg/m<span class="elsevierStyleSup">2</span>)</td><td>30 ± 4</td><td>31 ± 5</td><td>0.39</td></tr><tr align="left"><td>Heart failure, <span class="elsevierStyleItalic">n</span> (%)</td><td>4 (29)</td><td>2 (13)</td><td>0.67</td></tr><tr align="left"><td>Hypertension, <span class="elsevierStyleItalic">n</span> (%)</td><td>9 (59)</td><td>7 (47)</td><td>1</td></tr><tr align="left"><td>Dysrhythmia, <span class="elsevierStyleItalic">n</span> (%)</td><td>4 (23)</td><td>4 (27)</td><td>0.13</td></tr><tr align="left"><td>Diabetes mellitus, <span class="elsevierStyleItalic">n</span> (%)</td><td>5 (29)</td><td>4 (27)</td><td>1</td></tr><tr align="left"><td>Stroke, <span class="elsevierStyleItalic">n</span> (%)</td><td>0 (0)</td><td>1 (7)</td><td>0.39</td></tr><tr align="left"><td colspan="4"> </td></tr><tr align="left"><td colspan="4"><span class="elsevierStyleItalic">Sleep respiratory variables of initial diagnosis</span></td></tr><tr align="left"><td>AHI (events/h)</td><td>44 ± 18</td><td>52 ± 25</td><td>0.34</td></tr><tr align="left"><td>Central apnea index (/h)</td><td>10 ± 12</td><td>4 ± 6</td><td>0.16</td></tr><tr align="left"><td>Obstructive apnea index (/h)</td><td>18 ± 23</td><td>17 ± 16</td><td>0.91</td></tr><tr align="left"><td>Mixed apnea index (/h)</td><td>4 ± 4</td><td>9 ± 15</td><td>0.27</td></tr><tr align="left"><td>Hypopnea index (/h)</td><td>16 ± 10</td><td>13 ± 10</td><td>0.45</td></tr><tr align="left"><td>Cheyne–Stokes, <span class="elsevierStyleItalic">n</span> (%)</td><td>6 (37)</td><td>6 (40)</td><td>0.55</td></tr><tr align="left"><td>Mean nocturnal SaO<span class="elsevierStyleInf">2</span> (%)</td><td>92 ± 4</td><td>92 ± 4</td><td>0.94</td></tr><tr align="left"><td>Minimal nocturnal SaO<span class="elsevierStyleInf">2</span> (%)</td><td>72 ± 14</td><td>76 ± 12</td><td>0.44</td></tr><tr align="left"><td>Epworth sleepiness scale</td><td>12 ± 7</td><td>11 ± 6</td><td>0.78</td></tr><tr align="left"><td colspan="4"> </td></tr><tr align="left"><td colspan="4"><span class="elsevierStyleItalic">Arterial blood gases</span></td></tr><tr align="left"><td>PaCo<span class="elsevierStyleInf">2</span> (mmHg)</td><td>38 ± 3</td><td>37 ± 7</td><td>0.59</td></tr><tr align="left"><td>PaO<span class="elsevierStyleInf">2</span> (mmHg)</td><td>89 ± 13</td><td>91 ± 3</td><td>0.56</td></tr><tr align="left"><td>HCO<span class="elsevierStyleInf">3</span> (mmol/L)</td><td>25 ± 3</td><td>25 ± 3</td><td>0.97</td></tr></table><a name="t0005" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"></p><table><tr align="left"><td> </td><td>ASV group (<span class="elsevierStyleItalic">n</span> = 9)</td><td>PAP group (<span class="elsevierStyleItalic">n</span> = 7)</td><td><span class="elsevierStyleItalic">P</span> value</td></tr><tr align="left"><td colspan="4"><span class="elsevierStyleItalic">Hemodynamic parameters</span></td></tr><tr align="left"><td>LVFS (%)</td><td>35 ± 15</td><td>35 ± 4</td><td>0.96</td></tr></table><p class="elsevierStylePara">Heart failure was present in 20.6% of cases, hypertension in 53% and dysrhythmia in 12%. Twenty-nine percent of the patients had history of diabetes mellitus.</p><p class="elsevierStylePara">In both groups (PAP vs. ASV) there were no statistical differences in terms of age (mean 71 years ± 6 vs. 66 ± 10; <span class="elsevierStyleItalic">P</span> = 0.11), sex (88% male vs. 93%), BMI (mean 30 ± 4 vs. 31 ± 5; <span class="elsevierStyleItalic">P</span> = 0.39), Epworth sleepiness scale (mean 12 ± 7 vs. 11 ± 6; <span class="elsevierStyleItalic">P</span> = 0.78) or diagnostic AHI (mean 44 ± 18 vs. 52 ± 25). There was also no significant difference in terms of cardiovascular comorbidities (<a href="#t0005" class="elsevierStyleCrossRefs">Table 1</a>).</p><p class="elsevierStylePara">As this study is retrospective, not all the patients had an initial echocardiogram available, prior to PSG with ASV titration; in fact, echocardiographic evaluation before and after ASV titration was only available in 16 patients (9 in ASV group vs. 7 in PAP group). The median of the initial left ventricular shortening fraction was 35 ± 15 in ASV group and 35 ± 4 in PAP group with no differences between them (<span class="elsevierStyleItalic">P</span> = 0.96).</p><p class="elsevierStylePara">The diagnosis that led to an ASV study was treatment-emergent SA in 59.4% (44.4% in ASV group vs. 55.6% in PAP group), CSA and/or CSR in 40.6% (in 61.5% ASV group vs. 38.5% in PAP).</p><p class="elsevierStylePara">The indication for ASV titration was a suboptimal response to PAP. The summary of polysomnographic features of split-night of ASV titration is summarized in <a href="#t0010" class="elsevierStyleCrossRefs">Table 2</a>. During polysomnography ASV titration, the mean AHI was 7 ± 10 events/h after optimal pressure for ASV titration and the mean cumulative percentage time at a pulse oximetry oxygen saturation <90% was 11 ± 27%.</p><p class="elsevierStylePara">Table 2. Polysomnography findings of ASV titration.</p><a name="t0010" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"></p><table><tr align="left"><td> </td><td>PSG ASV titration</td></tr><tr align="left"><td>Apnea hypopnea index (events/h)</td><td>7 ± 10</td></tr><tr align="left"><td>Central apnea index (/h)</td><td>1 ± 4</td></tr><tr align="left"><td>Obstructive apnea index (/h)</td><td>4 ± 7</td></tr><tr align="left"><td>Mixed apnea index (/h)</td><td>2 ± 8</td></tr><tr align="left"><td>Respiratory events related arousals (/h)</td><td>1 ± 3</td></tr><tr align="left"><td>Respiratory arousal/awakening index</td><td>20 ± 16</td></tr><tr align="left"><td>Mean O<span class="elsevierStyleInf">2</span> sat</td><td>94 ± 2</td></tr><tr align="left"><td>Min O<span class="elsevierStyleInf">2</span> sat</td><td>89 ± 4</td></tr><tr align="left"><td>SpO<span class="elsevierStyleInf">2</span> < 90% (%)</td><td>11 ± 27</td></tr><tr align="left"><td>Sleep efficiency</td><td>69 ± 17</td></tr></table><p class="elsevierStylePara">After ASV titration, the mean follow-up was 25 ± 14 months. Both groups (ASV vs. PAP) were considered compliant as they used their device for more than 4 h per night and were similar: 77 ± 23% in ASV group (<span class="elsevierStyleItalic">P</span> = 0.191) and 88 ± 14% in PAP group (<span class="elsevierStyleItalic">P</span> = 0.482) (<a href="#f0005" class="elsevierStyleCrossRefs">Figure 1</a>) (<span class="elsevierStyleItalic">P</span> = 0.153). The average number of hours of daily use was 6h23 ± 2h13 in ASV group and 6h59 ± 1h08 in PAP group.</p><a name="f0005" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"><img src="320v21n03-" alt="Efficacy of adaptive servoventilation (ASV) on sleepiness."></img></p><p class="elsevierStylePara">Figure 1. Efficacy of adaptive servoventilation (ASV) on sleepiness.</p><p class="elsevierStylePara">In terms of sleepiness, both groups improved the Epworth sleepiness scale score after the initial diagnosis with a statistically significant difference (<span class="elsevierStyleItalic">P</span> = 0.016 in ASV group vs. <span class="elsevierStyleItalic">P</span> = 0.031 in PAP group). However, comparing only the final Epworth, no significant statistical difference was found between them: 6 ± 5 in ASV group and 7 ± 5 in PAP group (<span class="elsevierStyleItalic">P</span> = 5.06) (<a href="#f0010" class="elsevierStyleCrossRefs">Figure 2</a>).</p><a name="f0010" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"><img src="320v21n03-" alt="Compliance (%) of ASV and PAP group."></img></p><p class="elsevierStylePara">Figure 2. Compliance (%) of ASV and PAP group.</p><p class="elsevierStylePara">As shown in <a href="#f0015" class="elsevierStyleCrossRefs">Figure 3</a> there was a statistical difference in terms of residual AHI: mean AHI was 4 ± 3 in ASV group and 9 ± 3 in PAP group (<span class="elsevierStyleItalic">P</span> = 0.005).</p><a name="f0015" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"><img src="320v21n03-" alt="Impact of adaptive servoventilation (ASV) treatment on apnea hipbones index (AHI) (events/h)."></img></p><p class="elsevierStylePara">Figure 3. Impact of adaptive servoventilation (ASV) treatment on apnea hipbones index (AHI) (events/h).</p><p class="elsevierStylePara">We found no differences in terms of blood gases or left ventricular fractional shortening (ASV 33 ± 10% vs. PAP 32 ± 10%).</p><p class="elsevierStylePara"><a href="#t0015" class="elsevierStyleCrossRefs">Table 3</a> includes a summary of cardiovascular events. There was no difference in terms of non-fatal cardiovascular events (3 events in each group) but in PAP group 2 patients died of sudden death. These 2 patients had treatment-emergent SA and the ventilator mode was CPAP in one patient and BIPAP in the other. Both of them had diabetes, hypertension and alcoholism. One suffered from heart failure.</p><p class="elsevierStylePara">Table 3. Cardiovascular events.</p><a name="t0015" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"></p><table><tr align="left"><td> </td><td>ASV</td><td>PAP</td><td><span class="elsevierStyleItalic">P</span> value</td></tr><tr align="left"><td>Acute coronary syndrome</td><td>0</td><td>1</td><td>0.484</td></tr><tr align="left"><td>Arrhythmias</td><td>1</td><td>0</td><td>1</td></tr><tr align="left"><td>Progressive heart failure</td><td>2</td><td>1</td><td>1</td></tr><tr align="left"><td>Sudden death</td><td>0</td><td>2</td><td>0.484</td></tr></table><a name="sec0045" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Discussion</span><p class="elsevierStylePara">The efficacy of ASV for the treatment of Cheyne–Stokes respiration (CSR) associated with cardiac heart failure (CHF) was first reported in 2001 and confirmed subsequently in several short term studies.<a href="#bib32" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">11</span></a><span class="elsevierStyleSup">, </span><a href="#bib33" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">12</span></a><span class="elsevierStyleSup">, </span><a href="#bib34" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">13</span></a> Since then, longer-term studies (3–6 months) have compared ASV to CPAP and indicated that ASV is more efficient than CPAP in improving LVEF and decreasing the AHI over baseline.<a href="#bib35" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">14</span></a><span class="elsevierStyleSup">, </span><a href="#bib36" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">15</span></a><span class="elsevierStyleSup">, </span><a href="#bib37" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">16</span></a></p><p class="elsevierStylePara">Concerning other causes of central sleep apnea a recent study analyzed the role of ASV in treating patients with neurological or idiopathic central sleep apnea. This long-term study had a mean follow-up of 36 ± 18 months and concluded that ASV improved their AHI from 47.4 ± 19.8 to 6.9 ± 9.3/h [<span class="elsevierStyleItalic">P</span> < 0.001] and mean nocturnal SaO<span class="elsevierStyleInf">2</span> from 92.1 ± 2.6% to 93.6 ± 3.2% [<span class="elsevierStyleItalic">P</span> < 0.001].<a href="#bib38" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">17</span></a></p><p class="elsevierStylePara">Regarding treatment of treatment-emergent CSA, there is an important debate. Some studies argue that central sleep apnea events disappear a few months later with the maintenance of CPAP therapy<a href="#bib26" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">, </span><a href="#bib27" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">7</span></a><span class="elsevierStyleSup">, </span><a href="#bib28" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">8</span></a> but our experience has taught us that some central apneas persist even with the regular CPAP therapy. Several studies have analyzed the role of ASV in the treatment of treatment-emergent SA and have concluded that ASV is a leading treatment.<a href="#bib39" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">18</span></a> In the largest case series to date, ¾ of the 63 patients with Treatment emergent SA exhibited a drop in AHI to <10/h on ASV concluding that ASV is also an excellent option for these patients.<a href="#bib40" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">19</span></a></p><p class="elsevierStylePara">In our study, we demonstrate that ASV titration is an efficient treatment for patients with treatment-emergent CSA, CSA or CSR as it shows significant decreases of AHI and on Epworth sleepiness scale, compliance rate was high (with 77% compliant patients in ASV group) and the long-term tolerance was excellent.</p><p class="elsevierStylePara">Compared to PAP, results for our sample fully agree with previous studies since we found a statistical difference between the 2 groups in terms of AHI.</p><p class="elsevierStylePara">We did not demonstrate a difference between ASV and PAP in terms of LVFS improvement but only 16 patients had cardiac function evaluation before and after PSG for ASV titration and treatment decision. Therefore, it is difficult to evaluate the effect of the 2 types of ventilation concerning cardiac function because of the small number of patients.</p><p class="elsevierStylePara">We also did not find differences in terms of non-fatal cardiovascular events between the 2 groups but in the PAP group 2 patients died of sudden death.</p><p class="elsevierStylePara">There are some limitations of this study. First of all, some of the patients, because of problems due to reimbursement, were not treated with ASV although they had indication to start that mode of ventilation mode, so the number of the patients in the ASV group was small. Furthermore, as the study is retrospective, not all the patients had previously had an echocardiogram before PAP therapy so the comparison between the two ventilator modes concerning cardiac function cannot be made with confidence because of the small number of patients who had echocardiogram before and after PAP therapy.</p><a name="sec0050" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Conclusion</span><p class="elsevierStylePara">ASV is an effective 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 clinically relevant that the 2 patients who died of sudden death were treated with PAP.</p><a name="sec0055" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Ethical disclosures</span><a name="sec0060" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Protection of human and animal subjects</span><p class="elsevierStylePara">The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).</p><a name="sec0065" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Confidentiality of data</span><p class="elsevierStylePara">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p><a name="sec0070" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Right to privacy and informed consent</span><p class="elsevierStylePara">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p><a name="sec0075" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p class="elsevierStylePara">The authors have no conflicts of interest to declare.</p><p class="elsevierStylePara">Received 23 March 2014 <br></br>Accepted 15 August 2014 </p><p class="elsevierStylePara">Corresponding author. silvia_s_correia@hotmail.com</p>" "pdfFichero" => "320v21n03a90418840pdf001.pdf" "tienePdf" => true "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec640985" "palabras" => array:4 [ 0 => "ASV" 1 => "Treatment-emergent CSA" 2 => "CSA" 3 => "CSR" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:1 [ "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><br/><p class="elsevierStylePara">Adaptive 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.</p><span class="elsevierStyleSectionTitle">Objectives</span><br/><p class="elsevierStylePara">To compare the clinical impact of ASV with other forms of PAP in treating patients with treatment-emergent CSA, CSA and CSR.</p><span class="elsevierStyleSectionTitle">Methods</span><br/><p class="elsevierStylePara">Medical 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.</p><span class="elsevierStyleSectionTitle">Results</span><br/><p class="elsevierStylePara">ASV 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 ± 22 events/h.</p><p class="elsevierStylePara">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.</p><p class="elsevierStylePara">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 (<span class="elsevierStyleItalic">P</span> = 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).</p><span class="elsevierStyleSectionTitle">Conclusions</span><br/><p class="elsevierStylePara">These 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.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig1" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "descripcion" => array:1 [ "en" => "Efficacy of adaptive servoventilation (ASV) on sleepiness." ] ] 1 => array:7 [ "identificador" => "fig2" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "descripcion" => array:1 [ "en" => "Compliance (%) of ASV and PAP group." ] ] 2 => array:7 [ "identificador" => "fig3" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "descripcion" => array:1 [ "en" => "Impact of adaptive servoventilation (ASV) treatment on apnea hipbones index (AHI) (events/h)." ] ] 3 => array:6 [ "identificador" => "fig4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "descripcion" => array:1 [ "en" => "Efficacy of adaptive servoventilation (ASV) on sleepiness." ] ] 4 => array:6 [ "identificador" => "fig5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "descripcion" => array:1 [ "en" => "Compliance (%) of ASV and PAP group." ] ] 5 => array:6 [ "identificador" => "fig6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "descripcion" => array:1 [ "en" => "Impact of adaptive servoventilation (ASV) treatment on apnea hipbones index (AHI) (events/h)." ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib21" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Central sleep apnea: pathophysiology and treatment. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 7 | 18 |
| 2024 October | 68 | 52 | 120 |
| 2024 September | 82 | 64 | 146 |
| 2024 August | 112 | 95 | 207 |
| 2024 July | 79 | 84 | 163 |
| 2024 June | 80 | 75 | 155 |
| 2024 May | 71 | 68 | 139 |
| 2024 April | 78 | 53 | 131 |
| 2024 March | 63 | 52 | 115 |
| 2024 February | 70 | 49 | 119 |
| 2024 January | 72 | 30 | 102 |
| 2023 December | 49 | 44 | 93 |
| 2023 November | 59 | 41 | 100 |
| 2023 October | 63 | 45 | 108 |
| 2023 September | 51 | 30 | 81 |
| 2023 August | 43 | 27 | 70 |
| 2023 July | 53 | 29 | 82 |
| 2023 June | 41 | 30 | 71 |
| 2023 May | 70 | 37 | 107 |
| 2023 April | 65 | 22 | 87 |
| 2023 March | 127 | 22 | 149 |
| 2023 February | 97 | 31 | 128 |
| 2023 January | 48 | 20 | 68 |
| 2022 December | 73 | 22 | 95 |
| 2022 November | 100 | 55 | 155 |
| 2022 October | 76 | 41 | 117 |
| 2022 September | 42 | 33 | 75 |
| 2022 August | 53 | 39 | 92 |
| 2022 July | 49 | 46 | 95 |
| 2022 June | 43 | 35 | 78 |
| 2022 May | 47 | 43 | 90 |
| 2022 April | 55 | 38 | 93 |
| 2022 March | 57 | 63 | 120 |
| 2022 February | 40 | 42 | 82 |
| 2022 January | 51 | 39 | 90 |
| 2021 December | 40 | 50 | 90 |
| 2021 November | 53 | 39 | 92 |
| 2021 October | 56 | 59 | 115 |
| 2021 September | 41 | 30 | 71 |
| 2021 August | 46 | 23 | 69 |
| 2021 July | 30 | 18 | 48 |
| 2021 June | 40 | 27 | 67 |
| 2021 May | 53 | 32 | 85 |
| 2021 April | 131 | 91 | 222 |
| 2021 March | 85 | 34 | 119 |
| 2021 February | 57 | 23 | 80 |
| 2021 January | 44 | 16 | 60 |
| 2020 December | 47 | 5 | 52 |
| 2020 November | 57 | 15 | 72 |
| 2020 October | 62 | 23 | 85 |
| 2020 September | 53 | 29 | 82 |
| 2020 August | 67 | 23 | 90 |
| 2020 July | 104 | 17 | 121 |
| 2020 June | 101 | 31 | 132 |
| 2020 May | 87 | 15 | 102 |
| 2020 April | 80 | 11 | 91 |
| 2020 March | 75 | 15 | 90 |
| 2020 February | 51 | 21 | 72 |
| 2020 January | 66 | 18 | 84 |
| 2019 December | 79 | 19 | 98 |
| 2019 November | 70 | 11 | 81 |
| 2019 October | 78 | 22 | 100 |
| 2019 September | 74 | 18 | 92 |
| 2019 August | 142 | 17 | 159 |
| 2019 July | 130 | 18 | 148 |
| 2019 June | 151 | 14 | 165 |
| 2019 May | 129 | 16 | 145 |
| 2019 April | 133 | 29 | 162 |
| 2019 March | 152 | 11 | 163 |
| 2019 February | 141 | 9 | 150 |
| 2019 January | 146 | 32 | 178 |
| 2018 December | 74 | 5 | 79 |
| 2018 November | 43 | 0 | 43 |
| 2018 October | 50 | 17 | 67 |
| 2018 September | 26 | 8 | 34 |
| 2018 August | 37 | 22 | 59 |
| 2018 July | 36 | 18 | 54 |
| 2018 June | 35 | 18 | 53 |
| 2018 May | 41 | 20 | 61 |
| 2018 April | 95 | 16 | 111 |
| 2018 March | 43 | 21 | 64 |
| 2018 February | 10 | 9 | 19 |
| 2018 January | 11 | 19 | 30 |
| 2017 December | 16 | 16 | 32 |
| 2017 November | 23 | 18 | 41 |
| 2017 October | 15 | 14 | 29 |
| 2017 September | 17 | 15 | 32 |
| 2017 August | 30 | 13 | 43 |
| 2017 July | 17 | 11 | 28 |
| 2017 June | 23 | 20 | 43 |
| 2017 May | 21 | 23 | 44 |
| 2017 April | 17 | 6 | 23 |
| 2017 March | 16 | 14 | 30 |
| 2017 February | 6 | 12 | 18 |
| 2017 January | 8 | 13 | 21 |
| 2016 December | 16 | 4 | 20 |
| 2016 November | 5 | 3 | 8 |
| 2016 October | 2 | 3 | 5 |
| 2016 September | 3 | 1 | 4 |
| 2016 August | 3 | 5 | 8 |
| 2016 July | 4 | 7 | 11 |
| 2016 June | 0 | 9 | 9 |
| 2016 May | 3 | 7 | 10 |
| 2016 April | 19 | 1 | 20 |
| 2016 March | 41 | 19 | 60 |
| 2016 February | 39 | 36 | 75 |
| 2016 January | 35 | 25 | 60 |
| 2015 December | 30 | 18 | 48 |
| 2015 November | 19 | 27 | 46 |
| 2015 October | 25 | 29 | 54 |
| 2015 September | 45 | 39 | 84 |
| 2015 August | 55 | 51 | 106 |
| 2015 July | 44 | 40 | 84 |
| 2015 June | 54 | 58 | 112 |
| 2015 May | 160 | 145 | 305 |
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