Efficacy of Adaptive Servoventilation in Treatment of Complex and Central Sleep Apnea Syndromes

doi:10.1378/chest.07-1715

Chest

Volume 132, Issue 6, December 2007, Pages 1839-1846

https://doi.org/10.1378/chest.07-1715 Get rights and content

Background

Complex sleep apnea syndrome (CompSAS) is recognized by the concurrence of mixed or obstructive events with central apneas, the latter predominating on exposure to continuous positive airway pressure (CPAP). Treatment of CompSAS or central sleep apnea (CSA) syndrome with adaptive servoventilation (ASV) is now an option, but no large series exist describing the application and effectiveness of ASV.

Methods

Retrospective chart review of the first 100 patients who underwent polysomnography using ASV at Mayo Clinic Sleep Center.

Results

ASV titration was performed for CompSAS (63%), CSA (22%), or CSA/Cheyne Stokes breathing patterns (15%). The median diagnostic sleep apnea hypopnea index (AHI) was 48 events per hour (range, 24 to 62). With CPAP, obstructive apneas decreased, but the appearance of central apneas maintained the AHI at 31 events per hour (range, 17 to 47) [p = 0.02]. With bilevel positive airway pressure (BPAP) in spontaneous mode, AHI trended toward worsening vs baseline, with a median of 75 events per hour (range, 46 to 111) [p = 0.055]. BPAP with a backup rate improved the AHI to 15 events per hour (range, 11 to 31) [p = 0.002]. Use of ASV dramatically improved the AHI to a mean of 5 events per hour (range, 1 to 11) vs baseline and vs CPAP (p < 0.0001). ASV also resulted in an increase in rapid eye movement sleep vs baseline and CPAP (18% vs 12% and 10%, respectively; p < 0.0001). Overall, 64 patients responded to the ASV treatment with a mean AHI < 10 events per hour. Of the 44 successful survey follow-up patients contacted, 32 patients reported some improvement in sleep quality.

Conclusion

The ASV device appears to be an effective treatment of both CompSAS and CSA syndromes that are resistant to CPAP.

Section snippets

Definitions

Apneas and hypopneas were defined as previously described.⁵ Respiratory-related arousals (RERAs) were tabulated if associated with apneas, hypopneas, or with other indicators of airflow limitation not meeting criteria for apneas or hypopneas.¹² All indexes are expressed as the number of events divided by the hours of sleep.

Obstructive sleep apnea syndrome was diagnosed if AHI was ≥ 5 events per hour, or if the patient complained of sleepiness and the number of RERAs per hour was > 10 and CPAP

Results

The study population was 87% male with median age of 72 years (IQR, 59 to 78). Characteristics are summarized in Table 1. The diagnoses that led to an ASV study were CompSAS in 63%, CSA in 22%, and CSA/CSR in the remaining 15%. The indication for all ASV trials was a suboptimal response to CPAP, whether the CPAP trial was performed at our center or elsewhere. Patients had an average of three study segments completed, usually diagnostic polysomnography, CPAP titration, and an ASV trial. In some

Discussion

This is the first report of the clinical use of ASV in a consecutive series of patients. In patients with CSA, CSA/CSR, or CompSAS whose sleep-related breathing problems were not easily controlled with CPAP, we have shown that ASV resulted in a dramatic improvement in sleep-disordered breathing, as well as some improvement in sleep architecture. Furthermore, the device was very well tolerated and resulted in improvement in the symptoms of 32 of 44 contacted patients on follow-up.

CompSAS

Conclusion

ASV is a new treatment modality that has been shown effective in treating CSA, CSA/CSR, and CompSAS. Our findings clarify and extend prior observations, and suggest that ASV is an appropriate consideration to other positive airway pressure treatments and is effective for most patients with these nonobstructive sleep-related breathing disorders.

Telephone Questionnaire: Are You Currently Using the ASV?

If yes:

How long have you been using it?

How many hours per night on average?

Are you having problems with:

Mask comfort?

Leaks?

Alarms?

Pressure?

Residual snoring?

References (21)

SS Pusalavidyasagar et al.
Treatment of complex sleep apnea syndrome: a retrospective comparative review
Sleep Med
(2006)
T Cassina et al.
Clinical experience with adaptive support ventilation for fast-track cardiac surgery
J Cardiothorac Vasc Anesth
(2003)
S Nadar et al.
Positive pressure ventilation in the management of acute and chronic cardiac failure: a systematic review and meta-analysis
Int J Cardiol
(2005)
TD Bradley
Pro/con debate: CPAP should be used for central sleep apnea in congestive heart failure patients
J Clin Sleep Med
(2007)
S Javaheri
Pro/con debate: CPAP should not be used for central sleep apnea in congestive heart failure patients
J Clin Sleep Med
(2007)
S Javaheri
Treatment of central sleep apnea in heart failure
Sleep
(2000)
TI Morgenthaler et al.
Complex sleep apnea syndrome: is it a unique clinical syndrome?
Sleep
(2006)
S Javaheri
Effects of continuous positive airway pressure on sleep apnea and ventricular irritability in patients with heart failure
Circulation
(2000)
TD Bradley et al.
Continuous positive airway pressure for central sleep apnea and heart failure
N Engl J Med
(2005)
H Teschler et al.
Adaptive pressure support servo-ventilation: a novel treatment for Cheyne-Stokes respiration in heart failure
Am J Respir Crit Care Med
(2001)

There are more references available in the full text version of this article.

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The purpose of this review was to describe our management approach to patients with treatment-emergent central sleep apnea (TECSA). The emergence of central sleep apnea during positive airway pressure therapy occurs in approximately 8% of titration studies for OSA, and it has been associated with several demographic, clinical, and polysomnographic factors, as well as factors related to the titration study itself. TECSA shares similar pathophysiology with central sleep apnea. In fact, central and OSA pathophysiologic mechanisms are inextricably intertwined, with ventilatory instability and upper airway narrowing occurring in both entities. TECSA is a “dynamic” process, with spontaneous resolution with ongoing positive airway pressure therapy in most patients, persistence in some, or appearing de novo in a minority of patients. Management strategy for TECSA aims to eliminate abnormal respiratory events, stabilize sleep architecture, and improve the underlying contributing medical comorbidities. CPAP therapy remains a standard therapy for TECSA. Expectant management is appropriate given its transient nature in most cases, whereas select patients would benefit from an early switch to an alternative positive airway pressure modality. Other treatment options include supplemental oxygen and pharmacologic therapy.
Evaluation of the Impact of Body Position on Primary Central Sleep Apnea Syndrome
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To evaluate the impact of the body position on primary central sleep apnea syndrome.
Fifty-five subjects diagnosed with central sleep apnea (CSA) through polysomnographic examinations were prospectively enrolled in the study. All patients underwent cardiologic and neurologic examinations. Primary positional central sleep apnea (PCSA) was determined when the supine Apnea–Hypopnea Index (AHI) was greater than two times the non-supine AHI. The primary PCSA and non-PCSA groups were compared in terms of demographic characteristics, sleep parameters, and treatment approaches.
Overall, 39 subjects diagnosed with primary CSA were included in the study; 61.5% of the subjects had primary PCSA. There were no differences between the primary PCSA and non-PCSA groups regarding age, sex, body mass index (BMI), co-morbidities, and history of septoplasty. In terms of polysomnography parameters, AHI (P = .001), oxygen desaturation index (P = .002), the time spent under 88% saturation during sleep (P = .003), number of obstructive apnea (P = .011), mixed apnea (P = .009), and central apnea (P = .007) was lower in the primary PCSA group than in the non-PCSA group. Twenty-nine percent of the patients in the primary PCSA group were recommended position treatment and 71% were recommended positive airway pressure (PAP) therapy; all patients in the non-PCSA group were recommended PAP therapy.
Our results demonstrated that the rate of primary PCSA was high (61.5%) and primary PCSA was associated with milder disease severity compared with non-PCSA. The classification of patients with primary CSA regarding positional dependency may be helpful in terms of developing clinical approaches and treatment recommendations.
Evaluar el impacto de la posición del cuerpo en el síndrome de apnea central del sueño primaria.
En el estudio se incluyeron prospectivamente 55 sujetos con diagnóstico de apnea central del sueño (ACS) a través de sus estudios polisomnográficos. Todos los pacientes fueron sometidos a exámenes cardiológicos y neurológicos. La apnea central del sueño posicional (ACSP) se estableció cuando el índice de apnea-hipopnea (IAH) en posición supina fue más de dos veces mayor que el IAH en posición no supina. Se compararon los grupos de pacientes con ACSP primaria y sin ACSP en función de las características demográficas, los parámetros del sueño y los enfoques de tratamiento.
En total, se incluyeron en el estudio 39 sujetos con diagnóstico de ACS primaria. El 61,5% de los sujetos presentaban ACSP primaria. No hubo diferencias entre los grupos de ACSP primaria y sin ACSP con respecto a la edad, el sexo, el índice de masa corporal (IMC), las comorbilidades y los antecedentes de septoplastia. En cuanto a los parámetros de polisomnografía, el IAH (p = 0,001), el índice de desaturación de oxígeno (p = 0,002), el tiempo transcurrido con una saturación por debajo del 88% durante el sueño (p = 0,003) y el número de apneas obstructivas (p = 0,011), de apneas mixtas (p = 0,009) y de apneas centrales (p = 0,007) fueron menores en el grupo con ACSP primaria que en el grupo sin ACSP. Al 29% de los pacientes en el grupo de ACSP primaria se les recomendó tratamiento posicional y al 71% se les recomendó tratamiento de presión positiva de la vía aérea (PAP); a todos los pacientes del grupo sin ACSP se les aconsejó tratamiento PAP.
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Similarly to obstructive sleep apnea (OSA), CSA is known to be associated with adverse outcomes in cardiac patients.3 Positive airway pressure (PAP), specifically in the form of adaptive servo-ventilation (ASV), is efficacious in suppressing CSA events and has been reported to improve patients’ ventricular function and quality of life proved by both clinical trials and meta-analyses.5–9 However, whether long-term CSA treatment with PAP ameliorates CV prognosis is controversial.10,11
Despite the efficacy of adaptive servo-ventilation (ASV) in suppressing central sleep apnea (CSA), its impact on long-term outcomes is debatable. We aim to identify subjects with specific features who might benefit from ASV therapy.
Randomized clinical trials and comparative observational studies investigating the effects of ASV on cardiovascular (CV) and all-cause mortality and major adverse cardiovascular events (MACEs) in CSA patients were searched from PubMed, EMBASE, Cochrane library and Web of Science. Eligible studies were identified with relative risks (RR) of death and MACEs compared between patients treated by ASV and usual care.
A total of eight studies (three randomized controlled trials and five observational studies) including 2208 participants were selected for analysis. All-cause and CV mortality were not significantly reduced by ASV. Patients with nadir nocturnal saturation ≤ 80% (mean value) had lower risk of MACEs by ASV treatment compared with by usual care (RR, 0.18; p < 0.001). Patients with severe heart failure (HF), defined as left ventricular ejection fraction (LVEF) ≤ 33% (mean value), or HF of New York Heart Association (NYHA) classification of III/IV, did not have reduced risk of MACEs post ASV therapy. However, subjects with LVEF > 33% (RR, 0.35; p < 0.001) or NYHA Ⅰ/Ⅱ (RR, 0.35; p < 0.001) had significantly lower risk of MACEs by using ASV than by usual care.
Although ASV appears to not reduce CV and all-cause death for HF patients with extremely low LVEF, those with profound CSA associated hypoxemia or less severe HF still benefit from ASV therapy.

View all citing articles on Scopus

Dr. Morgenthaler received a loan of equipment from Olympus for study on vocal cord visualization during sleep, a loan of equipment from SenTec for different research protocol, and equipment and financial support from ResMed Inc, in 2004 for a different protocol. Dr. Gay received equipment from ResMed Inc., for study of ASV in a different research protocol, and equipment and financial support from 2004 to 2005.

This work was performed at Mayo Clinic, Rochester, MN.

The authors have no conflicts of interest to disclose.

View full text

Chest

Original ResearchSleep MedicineEfficacy of Adaptive Servoventilation in Treatment of Complex and Central Sleep Apnea Syndromes

Background

Methods

Results

Conclusion

Section snippets

Definitions

Results

Discussion

Conclusion

Telephone Questionnaire: Are You Currently Using the ASV?

Sleep Med

J Cardiothorac Vasc Anesth

Int J Cardiol

Pro/con debate: CPAP should be used for central sleep apnea in congestive heart failure patients

J Clin Sleep Med

Pro/con debate: CPAP should not be used for central sleep apnea in congestive heart failure patients

J Clin Sleep Med

Treatment of central sleep apnea in heart failure

Sleep

Complex sleep apnea syndrome: is it a unique clinical syndrome?

Sleep

Effects of continuous positive airway pressure on sleep apnea and ventricular irritability in patients with heart failure

Circulation

Continuous positive airway pressure for central sleep apnea and heart failure

N Engl J Med

Adaptive pressure support servo-ventilation: a novel treatment for Cheyne-Stokes respiration in heart failure

Am J Respir Crit Care Med

Original Research
Sleep Medicine
Efficacy of Adaptive Servoventilation in Treatment of Complex and Central Sleep Apnea Syndromes