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Assisted Ventilation for Heart Failure Patients with Cheyne-Stokes Respiration

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Assisted Ventilation for Heart Failure Patients with Cheyne-Stokes Respiration Copyright #ERS Journals Ltd 2002 Eur Respir J 2002; 20: 934–941 European Respiratory Journal DOI: 10.1183/09031936.00.02622001 ISSN 0903-1936 Printed in UK – all rights reserved Assisted ventilation for heart failure patients with Cheyne-Stokes respiration T. Ko¨hnlein*, T. Welte*, L.B. Tan#, M.W. Elliott} Assisted ventilation for heart failure patients with Cheyne-Stokes respiration. *Dept of Pulmonary and Intensive T. Ko¨hnlein, T. Welte, L.B. Tan, M.W. Elliott. #ERS Journals Ltd 2002. Care Medicine, Otto-von-Guericke- Universita¨t Magdeburg, Magdeburg, ABSTRACT: Patients with chronic congestive cardiac failure (CCF) frequently suffer # from central sleep apnoea syndrome (CSAS). Continuous positive airway pressure Germany. Institute for Cardiovascular Research and }Dept of Respiratory (CPAP) has been suggested as a treatment. The authors hypothesised that bilevel Medicine, St James9s University Hos- ventilation might be easier to initiate and superior to CPAP at correcting the sleep- pital Leeds, Leeds, UK. related abnormality of breathing in patients with CCF. After excluding those with a history suggestive of obstructive sleep apnoea, 35 Correspondence: T. Ko¨hnlein, Otto- patients with CCF (left ventricular ejection fraction v35%) were screened with over- von-Guericke-Universita¨t Magdeburg, night oximetry and the diagnosis of CSAS was established with polysomnography in 18. Zentrum Innere Medizin, Pneumologie Two 14-day cycles of CPAP (0.85 kPa (8.5 mbar)) or bilevel ventilation (0.85/0.3 kPa und Internistische Intensivmedizin, (8.5/3 mbar)) in random order, were compared in a crossover study. Leipziger Str. 44, D-39120 Magdeburg, Sixteen patients (13 males), mean age 62.0¡7.4 yrs completed the study. The Germany. ¡ Fax: 49 3916715420 pretreatment apnoea/hypopnoea index of 26.7 10.7 was significantly reduced by CPAP E-mail: [email protected] and bilevel ventilation to 7.7¡5.6 and 6.5¡6.6, respectively. The arousal index fell from 31.1¡10.0 per hour of sleep to 15.7¡5.4 and 16.4¡6.9, respectively. Significant and Keywords: Bilevel ventilation, central equal improvements with CPAP and bilevel ventilation were found for sleep quality, sleep apnoea syndrome, Cheyne-Stokes daytime fatigue, circulation time and New York Heart Association class. respiration, congestive heart failure, The authors conclude that continuous positive airway pressure and bilevel ventilation continuous positive airway pressure equally and effectively improve Cheyne-Stokes respiration in patients with congestive cardiac failure. Received: December 18 2001 Accepted after revision: May 13 2002 Eur Respir J 2002; 20: 934–941. T. Ko¨hnlein was funded with a long- term research fellowship from the European Respiratory Society. Central sleep apnoea syndrome (CSAS) with Heart rate, blood pressure, and the calculated work Cheyne-Stokes respiration (CSR) is common in load for the heart are periodically increased during patients with severe cardiac failure. Up to 45% of sleep. As a consequence, the stress upon the failing patients with a left ventricular ejection fraction of heart is multiplied [5]. Sympathetic activation is a f40% may suffer from this breathing disorder during well-documented, independent risk factor for progres- sleep [1, 2]. sion of cardiac dysfunction and sudden cardiac death Current concepts of the pathophysiology of CSR [6]. suggest it is caused by enhanced carbon dioxide Recent epidemiological studies have shown a sensitivity, delayed transfer of blood gas tension significantly worse survival for patients with left changes to the chemoreceptors and the influence of heart insufficiency and CSAS [7, 8]. ANDREAS et al. adjacent brain centres (circadian rhythms, sleep wake [9] concluded that CSR during sleep or wakefulness centre) upon the central control of breathing [3]. CSR is associated with mortality or the need for trans- is characterised by periodic changes of tidal volume, plantation within a few months. Therefore, treatment resulting in 30–60-s cycles of hyperventilation, alter- of CSR in combination with "optimised" medical nating with hypoventilation or apnoea in a crescendo therapy may influence the course of chronic heart decrescendo pattern. The resumption of respiration failure, quality of life and the survival of patients [10]. from apnoea is associated with arousals and episodes Continuous positive airway pressure (CPAP) and of sympathetic activation. These episodes may occur time-controlled bilevel ventilation (bilevel spontaneous/ several hundred times during the night in patients with timed) are both used as symptomatic approaches to severe CSAS [4]. The repeated arousals prevent the treat sleep disordered breathing, correct hypoxaemia, patient from entering the deeper recuperative stages of reduce arousals, decrease sympathetic tone, and sleep, which leads to daytime sleepiness and fatigue. improve sleep quality [11, 12]. However, the appli- Activation of the sympathetic nervous system coin- cation of CPAP to patients with CHF may be cides with low levels of blood and tissue oxygenation. problematic [13, 14]. CPAP requires a spontaneously VENTILATION FOR CHEYNE-STOKES RESPIRATION 935 breathing patient and will be ineffective for central (suspicion of) alcohol or drug abuse. Patients with any apnoeas, whereas timed bilevel ventilation is able to noncardiologic medication that would have a possible ventilate a patient even in the absence of spontaneous influence on the control of breathing (e.g. sedatives, respiratory effort. Furthermore, some patients find tranquillisers, theophylline) were also excluded. breathing out against positive pressure uncom- Any deterioration in the subject9s condition as a fortable. Bilevel ventilation has been suggested as an result of participation in this study, judged by clinical alternative, but little is known about the efficacy or assessment, polysomnography or from the patient9s tolerance of bilevel ventilation in these patients and, own impression, warranted immediate withdrawal in particular, it has not been compared to CPAP. The from the study. authors hypothesised that bilevel ventilation might The study was approved by the Local Research be more effective than CPAP in terms of reducing Ethics Committee of the Leeds Teaching Hospitals pathological respiratory events and be better tolerated NHS Trust. Informed written consent was obtained by patients. from every patient prior to study entry. The aim of this prospective randomised, non- blinded, crossover, clinical trial was to compare the effect of CPAP and bilevel ventilation on the Experimental protocol ventilatory pattern during sleep in a cohort of patients with CSAS during sleep. Secondary outcome para- The procedure for identifying patients with CSAS meters were the effect on blood oxygen saturation, consisted of two steps. First, potential patients were arousals from sleep, sleep quality, circulation time, provided with a miniature oxygen saturation record- quality of life, daytime fatigue, and New York Heart ing device (Minolta1 Pulsox-3i; Minolta (UK) Ltd, Association (NYHA) functional class. Milton Keynes, UK) for an overnight measurement at home. This recording was interpreted according to the study of STANIFORTH et al. [17]. If the oxygen Patients and methods saturation recording showed prolonged sections with regular fluctuations in oxygen saturation of w4% and Subjects if the percentage of the night (23–6 h) spent with an oxygen saturation of f90% was w5%, the recording Successive patients of both sexes, aged 18–80 yrs, was suggestive of nocturnal breathing abnormalities. were screened in a cardiac outpatient clinic at the Subjects with these findings underwent screening Leeds Teaching Hospitals National Health Service polysomnography in the sleep laboratory to establish (NHS) Trust (Leeds, UK) between April and or exclude the diagnosis of central sleep apnoea and November 2000. w CSR (see below for criteria). Patients with a 1 yr history of chronic left heart CSR patients were randomised and entered a failure, in NYHA functional class II and III due to crossover study design (fig. 1). The randomisation ischaemic heart disease or dilated cardiomyopathy, procedure was performed with closed envelopes con- qualified for the study. Furthermore, inclusion criteria taining a label for the first treatment mode. The were a left ventricular ejection fraction of f35%. interventions were treatment cycles with CPAP or The subjects had to be outpatients in stable clinical bilevel ventilation, with each cycle consisting of 12 condition over the last 3 months before study entry and their medical treatment was optimised, based on the guidelines of the European Society of Cardiology Overnight polysomnography to establish diagnosis [15]. Only minor changes in the dosage of diuretics, but no introduction or withdrawal of any other Overnight polysomnography to medication with an effect on the circulation or control start first intervention (CPAP or of breathing, were allowed in the 3 weeks prior to Treatment period of 14 days: bilevel ventilation) study entry and during participation in the study. The first and last night in the cardiologic assessment was provided by an indepen- dent cardiologist (L.B. Tan) who was blinded for the sleep lab, 12 nights at home Overnight polysomnography to course of the study. evaluate first intervention Exclusion criteria included any pulmonary or neurological disease that might affect ventilation or Wash-out period of 14 days the control of breathing (such as central alveolar hypoventilation syndrome, chronic
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