Effect of Inhaled 3% CO2 on Cheyne-Stokes Respiration in Congestive Heart Failure

Rd, Steens; Tw, Millar; X, Su; Biberdorf, D J; Buckle, Patricia; Ahmed, Mansoor M.; Mh, Kryger

doi:10.1093/sleep/17.1.61

Cited by 103 publications

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“…[23][24][25]29,30 The outcomes of therapy have also varied considerably, with limited evidence to establish the effectiveness of any therapy for CSA. [26][27][28][29]31,32 The majority of published literature has focused on the treatment of CSA secondary to congestive heart failure (CHF), [2][3][4][5][6][7][8][9][10][11][15][16][17][18][19][20][21][22][26][27][28][29] with very little data on patients with "primary" CSA 23,24 or CSA secondary to causes other than CHF. 33 In addition, there is very little data on the treatment of CSA related to opioid use and CSA that is concomitant with OSA.…”

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confidence: 99%

“…Thus, therapeutic options have varied markedly from positive airway pressure (PAP) devices, including continuous positive airway pressure (CPAP), [2][3][4][5][6] bilevel positive airway pressure therapy (BPAP), [7][8][9] and adaptive servoventilation, [10][11][12][13]20 to supplemental O 2 , 14-17 carbon dioxide, 21,22 and/or pharmacologic agents. [23][24][25]29,30 The outcomes of therapy have also varied considerably, with limited evidence to establish the effectiveness of any therapy for CSA. [26][27][28][29]31,32 The majority of published literature has focused on the treatment of CSA secondary to congestive heart failure (CHF), [2][3][4][5][6][7][8][9][10][11][15][16][17][18][19][20][21][22][26][27][28]…”

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Treatment of Central Sleep Apnea in US Veterans

Chowdhuri

Ghabsha

Sinha

et al. 2012

Journal of Clinical Sleep Medicine

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Background: There are no standard therapies for the management of central sleep apnea (CSA). Either positive pressure therapy (PAP) or supplemental oxygen (O 2 ) may stabilize respiration in CSA by reducing ventilatory chemoresponsiveness. Additionally, increasing opioid use and the presence of comorbid conditions in US veterans necessitates investigations into alternative titration protocols to treat CSA. The goal was to report on the effectiveness of titration with PAP, used alone or in conjunction with O 2 , for the management of CSA associated with varying comorbidities and opioid use. Methods: This was a retrospective chart review over 3 years, performed at a VA sleep disorders center. The effects of CPAP, CPAP+O 2 , and BPAP+O 2 , used in a step-wise titration protocol, on consecutive patients diagnosed with CSA were studied. Results: CSA was diagnosed in 162 patients. The protocol was effective in eliminating CSA (CAI ≤ 5/h) in 84% of patients. CPAP was effective in 48%, while CPAP+O 2 combination was effective in an additional 25%, and BPAP+O 2 in 11%. The remaining 16% were non-responders. Forty-seven patients (29%) were on prescribed opioid therapy for chronic pain, in whom CPAP, CPAP+O 2 , or BPAP+O 2 eliminated CSA in 54%, 28%, and 10% cases,, respectively. CPAP, CPAP+O 2 , and BPAP+O 2 each produced signifi cant declines in the AHI, CAI, and arousal index, and an increase in the SpO 2 .Conclusion: The data demonstrate that using a titration protocol with CPAP and then PAP with O 2 effectively eliminates CSA in individuals with underlying comorbid conditions and prescription opioid use. Comparative studies with other therapeutic modalities are required. S C I E N T I F I C I N V E S T I G A T I O N ST he treatment of central sleep apnea (CSA) continues to lack a universally recognized standard of care.1 Variable etiologies of CSA and the presence of concomitant disorders infl uence the choice of therapy. Thus, therapeutic options have varied markedly from positive airway pressure (PAP) devices, including continuous positive airway pressure (CPAP), 2-6 bilevel positive airway pressure therapy (BPAP), 7-9 and adaptive servoventilation, [10][11][12][13]20 to supplemental O 2 , 14-17 carbon dioxide, 21,22 and/or pharmacologic agents. [23][24][25]29,30 The outcomes of therapy have also varied considerably, with limited evidence to establish the effectiveness of any therapy for CSA. [26][27][28][29]31,32 The majority of published literature has focused on the treatment of CSA secondary to congestive heart failure (CHF), [2][3][4][5][6][7][8][9][10][11][15][16][17][18][19][20][21][22][26][27][28][29] with very little data on patients with "primary" CSA 23,24 or CSA secondary to causes other than CHF. 33 In addition, there is very little data on the treatment of CSA related to opioid use and CSA that is concomitant with OSA. 13,35 The latter entities are of increasing importance in the US veteran population due to the increased use of prescription opioid drugs for chronic pain control and the risk for opioi...

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Treatment of Central Sleep Apnea in US Veterans

Chowdhuri

Ghabsha

Sinha

et al. 2012

Journal of Clinical Sleep Medicine

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“…In addition, because there is theoretical evidence that CO 2 administration should suppress PB in adult humans (31,33) and because CO 2 administration has recently been used clinically in an attempt to control breathing instability in both adults (2,32,47) and infants (1), we also examined the effect of CO 2 administration on PB. Our immediate aim was to compare and contrast the effects of inspired hypoxic and hypercapnic gas on the unstable newborn respiratory control system.…”

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Impact of changes in inspired oxygen and carbon dioxide on respiratory instability in the lamb

Wilkinson¹,

Sia²,

Skuza³

et al. 2005

Journal of Applied Physiology

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. Impact of changes in inspired oxygen and carbon dioxide on respiratory instability in the lamb. J Appl Physiol 98: 437-446, 2005. First published October 8, 2004 doi:10.1152/japplphysiol.00532.2004We examined the effect of hypoxia and hypercapnia administered during deliberately induced periodic breathing (PB) in seven lambs following posthyperventilation apnea. Based on our theoretical analysis, the sensitivity or loop gain (LG) of the respiratory control system of the lamb is directly proportional to the difference between alveolar PO2 and inspired PO2. This analysis indicates that during PB, when by necessity LG is Ͼ1, replacement of the inspired gas with one of reduced PO2 lowers LG; if we made inspired PO2 approximate alveolar PO2, we predict that LG would be approximately zero and breathing would promptly stabilize. In six lambs, we switched the inspired gas from an inspiratory oxygen fraction of 0.4 to one of 0.12 during an epoch of PB; PB was immediately suppressed, supporting the view that the peripheral chemoreceptors play a pivotal role in the genesis and control of unstable breathing in the lamb. In the six lambs in which we administered hypercapnic gas during PB, breathing instability was also suppressed, but only after a considerable time lag, indicating the CO2 effect is likely to have been mediated through the central chemoreceptors. When we simulated both interventions in a published model of the adult respiratory controller, PB was immediately suppressed by CO2 inhalation and exacerbated by inhalation of hypoxic gas. These fundamentally different responses in lambs and adult humans demonstrate that PB has differing underlying mechanisms in the two species.Cheyne-Stokes respiration; hypoxia; hypercapnia; sleep apnea syndromes; control of breathing; periodic breathing PERIODIC BREATHING (PB), or Cheyne-Stokes respiration, appears under a wide range of physiological and clinical conditions. It is particularly prevalent during sleep, occurring at sea level in apparently normal-term and preterm infants (22,43), at high altitude in normal adults (27), and after hypoxic exposure in experimental animals (11,21). It also occurs in patients with congestive heart failure (36), with idiopathic central sleep apnea (52), with bilateral brain stem lesions (40), and in periodic obstructive sleep apnea (41). A form of PB can also be found in hibernating animals (7,34).Although it is often assumed that the underlying mechanisms causing PB in infants and adults are similar, in each case involving instability of the chemical control system that regulates breathing, there are some marked differences in the pattern of PB and its responses to changes in inspired gas that remain largely unexplained. For example, in preterm infants, the waxing and waning pattern of PB that is characteristic of the adult is replaced by a more or less abrupt on-off pattern that shows little change in tidal volume during the breathing phase (42); this pattern resembles that seen in hibernating animals (34). Furthermore, although the re...

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“…Nocturnal oxygen by nasal prongs reduces CSR by about 50% and consolidates sleep [1,[6][7][8]. Application of 3% CO 2 prevented CSR by increasing the arterial carbon dioxide tension (Pa,CO 2 ) above the apnoeic threshold [9] but sleep was adversely affected, this being attributed to the tight-fitting face mask used [10]. The hypothesis was tested that CO 2 in conjunction with O 2 given by nasal prongs is efficacious in the treatment of CSR.…”

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Treatment of Cheyne-Stokes respiration with nasal oxygen and carbon dioxide

Andreas

Weidel²,

Hagenah³

et al. 1998

Eur Respir J

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Cheyne-Stokes respiration (CSR) during sleep is common in patients with severe congestive heart failure (CHF). It induces repetitive oxygen desaturations and impairs sleep [1,2]. Disturbed sleep is likely to cause daytime symptoms and the repetitive oxygen desaturations and arousals increase sympathetic activity as well as right and left ventricular afterload [3] and may thus further impede left ventricular function and exercise tolerance [4][5][6]. Effective treatment for CSR is therefore needed. Nocturnal oxygen by nasal prongs reduces CSR by about 50% and consolidates sleep [1,[6][7][8]. Application of 3% CO 2 prevented CSR by increasing the arterial carbon dioxide tension (Pa,CO 2 ) above the apnoeic threshold [9] but sleep was adversely affected, this being attributed to the tight-fitting face mask used [10]. The hypothesis was tested that CO 2 in conjunction with O 2 given by nasal prongs is efficacious in the treatment of CSR. Plasma catecholamines were measured, to evaluate possible effects on sympathetic activity. Methods Subjects and protocolAll patients with severe heart failure admitted to the department of cardiology were candidates for the study.Patients under the age of 75 yrs were eligible if they met the following criteria: at least one episode of cardiac decompensation, ejection fraction ð35%, stable condition on cardiac medication and evidence of CSR by nocturnal polysomnography. Exclusion criteria were myocardial infarction within 1 yr of entry, significant obstructive lung disease as defined by a forced expiratory volume in one second (FEV1)/forced vital capacity (FVC) <70%, primary valvular heart disease, tibial oedema or evidence of obstructive sleep apnoea (more than five obstructive apnoeas·h -1 ). Plasma catecholamines were evaluated in 15 healthy subjects (age 53.2±5.3 yrs) without significant sleep-disordered breathing. The study was approved by the local ethics committee. Informed written consent was obtained from all subjects.The study was designed as a single-blind, placebo-controlled trial. After an accommodation night where no treatment was applied the patients received air as well as O 2 plus CO 2 in a randomized, cross-over fashion on two consecutive nights. Polysomnography was performed during all three nights. Oxygen was given with a flow rate of 2 L·min -1 by nasal prongs and CO 2 was admixed simultaneously with a flow rate of 0.2-1 L·min -1 . Accordingly, the flow rate of the mixture was 2.2-3 L·min -1 . CO 2 flow rate was regulated depending on the transcutaneous carbon dioxide tension (Ptc,CO 2 ), which was not allowed to increase >7.3 kPa (55 mmHg) and on the occurrence of In conclusion, nocturnal O 2 plus CO 2 improves Cheyne-Stokes respiration in patients with congestive heart failure but has adverse effects on the sequel of CheyneStokes respiration, namely sympathetic activation. Eur Respir J 1998; 12: 414-419.

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Effect of Inhaled 3% CO2 on Cheyne-Stokes Respiration in Congestive Heart Failure

Cited by 103 publications

References 0 publications

Treatment of Central Sleep Apnea in US Veterans

Treatment of Central Sleep Apnea in US Veterans

Impact of changes in inspired oxygen and carbon dioxide on respiratory instability in the lamb

Treatment of Cheyne-Stokes respiration with nasal oxygen and carbon dioxide

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