Nasal continuous positive airway pressure in stroke patients with sleep apnoea: a randomized treatment study

Abstract

The authors have investigated whether treatment of sleep apnoea with nasal continuous positive airway pressure (nCPAP) improves depressive symptoms, personal activities of daily living (ADL), cognitive functioning and delirium in patients that have suffered a stroke.Sixty-three patients consecutively admitted to a stroke rehabilitation unit 2–4 weeks after a stroke, with an apnoea/hypopnoea index ≥15, were randomized to either nCPAP treatment (n=33) or a control group (n=30). Four patients dropped out after randomization. Both groups were assessed at baseline and after 7 and 28 nights using the Montgomery-Åsberg Depression Rating Scale (MADRS), Barthel-ADL index, and the Mini-Mental State Examination (MMSE) scale.Compared to the control group, depressive symptoms (MADRS total score) improved in patients randomized to nCPAP treatment (p=0.004). No significant treatment effect was found with regard to delirium, MMSE or Barthel-ADL index. Delirium and low cognitive level (MMSE score) explained poor compliance with nCPAP.Depressive symptoms are reduced through nasal continuous positive airway pressure treatment in patients with severe stroke and sleep apnoea. Compliance with nasal continuous positive airway pressure treatment is a problem in stroke patients, especially when delirium and severe cognitive impairment occur.

Effect of transnasal insufflation on sleep disordered breathing in acute stroke: a preliminary study

“…The adherence to CPAP treatment seems even lower in stroke patients with SDB. With the exception of some studies performed in the rehabilitation poststroke setting and in selected patients showing higher adherence rates [10][11][12], reported CPAP compliance in the acute [13][14][15][16] and sub-acute stroke phase [12,[17][18][19] is around 25-50%. Most patients had stroke-related problems that caused non-compliance, including facial palsy inducing CPAP mask leaks [20].…”

Diagnosing and Treating Sleep Apnea in Patients With Acute Cerebrovascular Disease

“…Three randomized controlled trials demonstrated improvements in the NIHSS score among patients treated in the acute stroke period; however, these studies were limited by small sample sizes (ranging from 32 to 55 patients) and short follow‐ups (ranging from 8 to 90 days) 2, 4, 7. In contrast to the favorable evidence supporting the diagnosis and treatment of sleep apnea in the acute stroke or TIA period, randomized controlled trials evaluating the use of CPAP in patients with subacute and chronic stroke have reported mixed results 3, 22, 23, 24. The SAVE (Sleep Apnea Cardiovascular Endpoints) trial, for example, recruited patients with established cardiovascular disease or cerebrovascular disease, including patients who were at least 3 months poststroke 25.…”

Rehabilitation of Cardiovascular Disorders and Sleep Apnea

“…There are several reasons for poor compliance, including spontaneous improvement of SDB, lack of excessive daytime sleepiness in some patients, and motor (facial and bulbar palsy) and cognitive (confusional states, dementia, aphasia) deficits. Compliance has been reported to be as low as 25% to 50% in the acute 39,53,113,116,117 or subacute 69,74,114 stroke phase, whereas other groups reported rates as high as 70% in the rehabilitation setting. 56 This finding indicates the importance of CPAP acclimation by skilled respiratory therapists.…”

“…28 In contrast, the presence of OSA in the setting of stroke is associated with unfavorable clinical course, including early neurologic worsening, delirium, depressed mood, impaired functional capacity and cognition, longer period of hospitalization and rehabilitation, and increased mortality. 1,7,9,10,36,37,[68][69][70][71][72] In addition, severe OSA not only increases the risk of stroke recurrence but also increases the incidence of fatal and nonfatal cardiovascular events as well as sudden death during sleep. 44,[73][74][75] The higher blood pressure and its swing during episodes of upper airways obstruction lead to worse outcome following stroke.…”

“…76 Treatment of coexisting OSA decreases both nocturnal and diurnal blood pressure 56,110 and as a result reduces risk of stroke recurrence, 111 reduces mortality, 74 and improves quality of life. 56, 69 Because SDB improves after the acute phase of stroke, auto-CPAP systems may be preferable. 47,112 Among the most prominent potential benefits of CPAP therapy are motor and functional outcomes.…”