Nocturnal nasal high-flow oxygen therapy in elderly patients with concomitant chronic obstructive pulmonary disease and obstructive sleep apnea

Abstract

Purpose The coexistence of obstructive sleep apnea (OSA) and chronic obstructive pulmonary disease (COPD) is known as “overlap syndrome” (OS). Patients with OS are usually older than patients with OSA alone, suffer from more profound oxygen desaturation during the obstructive events often accompanied by sustained nocturnal hypoventilation. Although oxygen-enriched positive airway pressure (PAP) is the treatment of choice in these patients, this therapy is often poorly tolerated particularly by the elderly. The aim of this study was to assess the usefulness of nocturnal oxygen therapy via nasal high flow (NHF-OT) as a possible alternative to PAP in patients with OS. Methods Patients > 65 years old with OS and nocturnal respiratory failure (time spent below SaO2 90% (T90) > 30%) had cardio-respiratory monitoring performed at baseline, during NHF-OT, or during conventional oxygen therapy (COT). Results A total of 40 patients were enrolled in the study. NHF-OT significantly reduced the apnea–hypopnea index (AHI) in all patients compared to baseline and COT. The mean basal AHI was 25.4 ± 8.6. During COT and NHF-OT, the AHI was 19.4 ± 7 and 5.4 ± 4.6, respectively (P < 0.001) and 19 patients reached an AHI < 5 during NHF-OT. The mean nocturnal SaO2% was 86.2 ± 2.6 at baseline and at equivalent FiO2 it significantly increased to 91.8 ± 2.4 during COT and to 93.9 ± 2.5 during NHF-OT (P < 0.001). The T90% was 48.7 ± 20.1 at baseline, 16.8 ± 11.7 during COT, and 8.8 ± 8.0 during NHF-OT (P < 0.001). Conclusions In elderly patients with OS, nocturnal treatment with NHF-OT significantly reduces obstructive episodes and improves oxygenation. As the treatment is generally well tolerated compared to PAP, NHF-OT may be a possible alternative therapy in this subgroup of patients.

Association of Prolonged Nocturnal Hypoxemia with Clinical Worsening in Patients with Chronic Thromboembolic Pulmonary Hypertension Undergoing Pulmonary Endarterectomy

“…The apnea-hypopnea index (AHI), the percentage of recording time with of 90% (T90), and the oxygen desaturation index (ODI) were used to assess hypoxemia. T90 of 30% was considered a nocturnal hypoxemia indicator [ 12 , 13 ]. Other hypoxia-related parameters evaluated included the mean , the minimum , the mean hypopnea time (HT), and apnea time (AT).…”

Alternative Sleep Apnea Treatment: Reply

“…We would like to close our comments by sharing the most recent clinical study demonstrating the effectiveness of high-flow nasal oxygen therapy (30 to 60 l/min with oxygen concentration titrated to increase awake Sp o 2 by 3 to 4%) for treatment of the overlap syndrome. 6 Yes, all issues raised by Roy et al are clinically relevant and to be fully answered in the near future.…”

Treatment of Sleep Apnea and Reduction in Blood Pressure: The Role of Heart Rate Response and Hypoxic Burden

“…In contrast to CPAP, nocturnal supplemental oxygen (NSO) therapy has not systematically been shown to change BP in individuals with OSA, 19 potentially due to lower efficacy than CPAP 20–23 and inadequate selection of individuals using apnea-hypopnea index (AHI), which fails to fully capture the severity (ie, depth and duration) of the intermittent hypoxia, which contributes to increased sympathetic overactivity and systemic inflammation 24,25 and is considered the main exposure for the NSO therapy. 26–31…”

“…16 Notably, even a small reduction in BP is associated with a decreased risk of stroke, coronary heart disease, and heart failure. 17,18 In contrast to CPAP, nocturnal supplemental oxygen (NSO) therapy has not systematically been shown to change BP in individuals with OSA, 19 potentially due to lower efficacy than CPAP [20][21][22][23] and inadequate selection of individuals using apnea-hypopnea index (AHI), which fails to fully capture the severity (ie, depth and duration) of the intermittent hypoxia, which contributes to increased sympathetic overactivity and systemic inflammation 24,25 and is considered the main exposure for the NSO therapy. [26][27][28][29][30][31] We have previously shown that quantitative measures of OSA severity and its physiological consequences, such as heart rate response (ΔHR) and hypoxic burden (HB), may better predict cardiovascular outcomes than the AHI.…”