Noninvasive positive pressure ventilation (NPPV) is an important tool in the management of acute and chronic respiratory failure. Traditionally, continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BPAP) have been the most commonly utilized modes for these purposes. Newer hybrid modes of NPPV, such as average volume-assured pressure support (VAPS), combine the properties of both volume- and pressure-controlled NPPV and represent another tool in the treatment of acute and chronic respiratory failure. Evidence demonstrating the superiority of VAPS over BPAP is sparse, but there have been studies that have demonstrated comparable efficacy between the two modes. The use of VAPS in acute hypercapnic respiratory failure has shown better clearance of CO2 compared to BPAP, due to its property of delivering a more assured tidal volume. This, however, did not lead to a decrease in hospital-days or improved mortality, relative to BPAP. The studies evaluating VAPS for chronic respiratory failure involve small sample sizes but have shown some promise. The benefits noted with VAPS, however, did not translate into increased survival, decreased hospitalizations or improved quality of life compared to BPAP. The limited evidence available suggests that VAPS is equally effective in treating acute and chronic respiratory failure compared to BPAP. Overall, the evidence to suggest superiority of one mode over the other is lacking. There is a need for larger studies before firm conclusions can be made.
Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder characterized by repeated episodes of obstructed (apnea) or reduced (hypopnea) airflow in the upper airway during sleep. Obstructive sleep apnea results in variable arterial oxygen desaturations and arousals leading to sleep fragmentation. Most patients with OSA first come to the attention of a clinician when they complain of daytime sleepiness or when their bed partner reports loud snoring and witnessed episodes. Obstructive sleep apnea is associated with impaired quality of life, cardiovascular disease, metabolic syndrome, and motor vehicle accidents, yet the disorder remains undiagnosed in a significant portion of the population. Overnight polysomnography, whether facility-based or portable, is required for appropriate patient diagnosis. Portable monitoring can be used in patients with a high pre-test probability for moderate-to-severe OSA, who are without significant comorbidities. Management of OSA requires a long-term multidisciplinary approach. Continuous positive airway pressure (CPAP) remains the mainstay of treatment for patients with moderate-to-severe OSA. Oral appliances may be indicated in patients with mild-to-moderate OSA who do not wish to use CPAP. Surgical therapy is generally reserved for selected patients in whom CPAP or oral appliance are not an option.
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