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Urgent Need to Improve PAP Management: The Devil Is in Two (Fixable) Details

Several high-profile, large prospective sleep apnea therapy trials have failed to meet expected outcomes: Apnea Positive Pressure Long-term Efficacy Study (APPLES) (cognition),1 the Treatment of Predominant Central Sleep Apnoea by Adaptive Servo Ventilation in Patients With Heart Failure (SERVE-HF) trial (heart failure),2 the Canadian Positive Airway Pressure Trial (CANPAP), the Sleep Apnea cardioVascular Endpoints (SAVE) study (general cardiovascular),3 and the Heart Bio-marker Evaluation in Apnea Treatment (HeartBEAT) (metabolic/hemodynamic).4 Each theoretically had the power to positively influence practice, but instead have cast doubt on the staple of our field: positive airway pressure. Struggling to navigate these findings, experts have invoked explanations ranging from inadequate use, too-short duration of therapy, overwhelming disease pathophysiology, treatment initiated too late in evolution of disease, and unknown pathophysiological constructs.

Central sleep apnoea—a clinical review

Central sleep apnoea—a clinical review

Effect of added dead space on sleep disordered breathing at high altitude. - PubMed - NCBI

Baseline data revealed two clearly distinct groups: one with severe sleep disordered breathing (n=5, AHI>30) and the other with moderate to no disordered breathing (n=7, AHI<30). DS markedly improved breathing in the first group (baseline vs DS): apnea hypopnea index (AHI) 70.3 ± 25.8 vs 29.4 ± 6.9 (p=0.013), oxygen desaturation index (ODI): 72.9 ± 24.1/h vs 42.5 ± 14.4 (p=0.031), whereas it had no significant effect in the second group or in the total population. Respiratory events were almost exclusively central apnea or hypopnea. Microarousal index, sleep efficiency, and sleep architecture remained unchanged with DS. A minor increase in mean PtcCO(2) (n=3) was observed with DS.

Effects of inhaled CO2 and added dead space on idiopathic central sleep apnea | Journal of Applied Physiology

In summary, we have demonstrated that an abrupt reduction inFET CO 2 FETCO2 immediately precedes the onset of the central apneas in patients with ICSAS. Furthermore, we have shown for the first time that inhalation of a CO2-enriched gas or addition of dead space eliminates central apneas and hypopneas in these patients in association with an increase inFET CO 2 FETCO2 and Ptc CO 2 tcCO2 and a dampening of breath-to-breath oscillations ofFET CO 2 FETCO2 . These findings provide compelling evidence that the mechanism for initiation of central hypopneas and apneas in ICSAS is a reduction inPa CO 2 PaCO2 toward or below the apneic threshold, respectively. Our data further indicate that the mechanism for abolition of these events by CO2 inhalation and addition of dead space is by increasing and stabilizingPa CO 2 PaCO2 above the apneic threshold. Taken together, these findings indicate that ICSAS is a disorder of respiratory control system instability that isPa CO 2 PaCO2 dependent. Although the purpose of this study was not to test the clinical effects of increasingPa CO 2 PaCO2 , our findings that CO2 inhalation and addition of dead space eliminate central apneas and hypopneas point to their potential as treatments for this disorder. More studies over longer time periods will be required to test the therapeutic potential of these approaches.

Treatment Benefits of the remedē® System Sustained Through 36 Months in Patients with Central Sleep Apnea | Respicardia

The latest results build upon prior published data in The Lancet and the American Journal of Cardiology which demonstrated that the remedē System significantly reduces the severity of CSA and improves sleep, quality of life and patient satisfaction,3 and the benefits are sustained.4

Sleep Apnea: Oral appliance could help you (and your partner) sleep better -- ScienceDaily

The Department of Orthodontics at Hiroshima University Hospital developed an oral appliance to help patients with mild to moderate sleep apnea. This appliance brings the jawbone forward to enlarge the air passageways at the back of their mouth. Each appliance is custom made for each patient and allows jaw movement, so it doesn't affect patient's teeth or change the shape of their face. "This is like when you have to use glasses, you have to wear them every time you want to see properly so [patients] have to wear this appliance every time [they] want to sleep better." according to Dr. Ueda.