Treating Chronic Hypoventilation With Automatic Adjustable Versus Fixed EPAP Intelligent Volume-Assured Positive Airway Pressure Support (iVAPS): A Randomized Controlled Trial

McArdle, Nigel; Rea, Clare Siobhan; King, Stuart; Maddison, Kathleen J.; Ramanan, Dinesh; Ketheeswaran, Sahisha; Erikli, Lisa; Baker, Vanessa A.; Armitstead, Jeff; Richards, Glenn; Singh, Bhajan; Hillman, David R.; Eastwood, Peter R.

doi:10.1093/sleep/zsx136

Cited by 33 publications

(33 citation statements)

References 34 publications

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“…The results of our study show an outcome similar to a recent investigation of AutoEPAP in patients with both chronic hypoventilation and upper airway obstruction . However, there were some differences between the studies.…”

Section: Discussionsupporting

confidence: 88%

“…The results of our study show an outcome similar to a recent investigation of AutoEPAP in patients with both chronic hypoventilation and upper airway obstruction. 16 However, there were some differences between the studies. We evaluated both ventilationdependent and non-dependent patients using a home ventilator, versus non-dependent patients using a bilevel device in the previous study.…”

Section: Discussionmentioning

confidence: 98%

“…Such an AutoEPAP algorithm has recently been incorporated into the intelligent VAPS (iVAPS) mode to help maintain airway patency. A recent randomized clinical trial of the iVAPS AutoEPAP algorithm showed non‐inferiority to fixed EPAP in patients with chronic hypoventilation, predominantly in patients with OHS and COPD who are not ventilator‐dependent.…”

Section: Introductionmentioning

confidence: 99%

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Automatic EPAP intelligent volume‐assured pressure support is effective in patients with chronic respiratory failure: A randomized trial

et al. 2019

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Background and objective Patients with chronic respiratory failure are increasingly managed with domiciliary non‐invasive ventilation (NIV). There may be limited ability to provide NIV titration for these complex patients, and ventilatory requirements and upper airway support needs may change over time. Therefore, an automatically adjusting expiratory positive airway pressure (AutoEPAP) algorithm may offer advantages over manually adjusted EPAP for treating these patients. This study compared 4% oxygen desaturation index (ODI4%) values during the use of an AutoEPAP algorithm versus manual EPAP titration with the intelligent volume‐assured pressure support (iVAPS) algorithm. Methods This prospective, single‐blind, randomized, crossover study was conducted at six US sites. Patients with chronic respiratory failure (neuromuscular disease, chronic obstructive pulmonary disease, obesity hypoventilation and other aetiologies) and an apnoea–hypopnoea index of >5/h who were already established NIV users underwent a single night of NIV with the iVAPS manual EPAP and iVAPS AutoEPAP in the sleep laboratory in random order. Results A total of 38 patients constituted the study population. Mean ODI4% was statistically non‐inferior with AutoEPAP versus manual EPAP (P < 0.0001). There was no difference in the effect on ODI4% across respiratory failure subgroups. Ventilation parameters and gas exchange were similar with either NIV mode, indicating equally effective treatment of respiratory failure. Sleep parameters were improved during AutoEPAP versus manual EPAP. Conclusion A single night of NIV using the iVAPS with AutoEPAP algorithm was non‐inferior to a single night of iVAPS with manual EPAP titration in patients with respiratory failure.Clinical Trial Registration: NCT02683772 at http://clinicaltrials.gov

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Section: Discussionsupporting

confidence: 88%

Section: Discussionmentioning

confidence: 98%

Section: Introductionmentioning

confidence: 99%

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Automatic EPAP intelligent volume‐assured pressure support is effective in patients with chronic respiratory failure: A randomized trial

et al. 2019

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“…No difference in mean AHI or other PSG‐derived sleep and breathing variables was seen between modes with self‐reported sleep quality also similar. However, there were some individual patient differences in response to the two modes, and while the authors were unable to identify specific predictors for this, post hoc analysis suggested leaks in the AutoEPAP mode might influence control of OSA . A subsequent, multicentre randomized study of 38 patients with chronic respiratory failure and AHI > 5 h previously established on BPAP (either fixed and Va modes) has likewise found the use of AutoEPAP to be non‐inferior to manually titrated EPAP in controlling upper airway obstruction during a single night of Va‐BPAP therapy .…”

Section: Volume‐assured Pressure Supportmentioning

confidence: 98%

Advances in non‐invasive positive airway pressure technology

Piper

2019

Respirology

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Non‐invasive ventilation (NIV) has become the standard of care for patients with a range of respiratory and sleep breathing disorders. Technological advances have enabled the development of several newer modes of automatically adapting NIV suitable for patients with more complex breathing abnormalities that may be difficult to manage effectively with more traditional positive airway pressure therapy. These modes allow for more stable ventilation when fluctuating ventilation requirements occur such as in positional upper airway obstruction or state‐related variations in respiratory mechanics and drive. Adaptive servoventilation (ASV) is designed for patients with periodic breathing and central apnoeas in whom carbon dioxide levels are normal to low, with the goal of therapy to dampen and stabilize ventilation. In contrast, volume‐assured pressure support is used in diagnostic groups characterized by hypoventilation, where targeting an effective level of ventilation irrespective of sleep stage or body position is required. These newer modes have the potential to simplify and optimize ventilation, although at present there is no evidence that they are clinically superior to standard home ventilation techniques. The complexity and differences in algorithms and features of various device brands, along with a limited evidence base documenting longer term outcomes, complicate decisions around which patient phenotypes are best suited to these newer modes. In‐built sensor and data storage capabilities of newer home ventilation devices provide the opportunity for earlier recognition of issues with ventilation and to guide corrective action. Further work is needed to determine how this impacts longer term clinical outcomes.

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“…This combined mode may be advantageous in selected patients with OHS/OSA or other forms of combined hypoventilation and obstructive or central sleep apnoea, but no scientific evidence is available to date to demonstrate its superiority over standard NIV modes [37]. …”

Section: Ventilator Mode and Settingsmentioning

confidence: 99%

Frontiers in Clinical Practice of Long-Term Care of Chronic Ventilatory Failure

Schwarz

Bloch

2019

Respiration

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Home mechanical ventilation (HMV) is an effective long-term treatment for chronic hypercapnic respiratory failure. In addition to the established practice of providing HMV for the treatment of chronic ventilatory failure in slowly progressive neuromuscular and chest wall disease, there is accumulating evidence for improvement of quality of life and prolongation of survival by HMV in highly prevalent diseases like chronic obstructive pulmonary disease and ever-increasing obesity hypoventilation syndrome as well as rapidly progressive neuromuscular disease. The key concepts for successful HMV are an experienced team selecting the right patients, timely initiation of adequate ventilation via an appropriate interface, and monitoring effectiveness during regular long-term follow-up. Coaching of patients with chronic respiratory failure on long-term HMV within a dedicated service and collaborations with community services for home care are essential. The current review describes various important practical aspects of HMV that remain frontiers in the implementation of the current knowledge in clinical practice and may help in providing effective HMV to all those in need.

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Treating Chronic Hypoventilation With Automatic Adjustable Versus Fixed EPAP Intelligent Volume-Assured Positive Airway Pressure Support (iVAPS): A Randomized Controlled Trial

Abstract: In patients with chronic hypoventilation using iVAPS, the AutoEPAP algorithm was noninferior to FixedEPAP over a single night's therapy.

Cited by 33 publications

References 34 publications

Automatic EPAP intelligent volume‐assured pressure support is effective in patients with chronic respiratory failure: A randomized trial

Automatic EPAP intelligent volume‐assured pressure support is effective in patients with chronic respiratory failure: A randomized trial

Advances in non‐invasive positive airway pressure technology

Frontiers in Clinical Practice of Long-Term Care of Chronic Ventilatory Failure

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