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

Abstract

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.

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

“…Note that LG O 2 and LG CO 2 are calculated at a phase shift of 180°. The magnitude of the mean arterial PO2 and PCO2 at the lung and carotid bodies, which are required in the calculation of LG, are computed at each instant in time using a center-weighted moving average technique, with a window size of 30 s. traditional view of PB being an oscillation about a fixed apneic threshold for CO 2 (38) is not applicable to the lamb since the oscillation in Pa O 2 apparently dominates the generation of PB in this species. Second, the effect of inspired CO 2 on the resolution of PB might be accelerated in the adult human because of the brisk carotid body response to CO 2 , a feature not present in the lamb.…”

“…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.…”

Treatment of Central Sleep Apnea in US Veterans

“…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.…”

“…[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.…”

Tratamento da respiração de Cheyne-Stokes em pacientes com insuficiência cardíaca congestiva

“…Special attention should be given to the patients with obstructive apneas, as the benzodiazepine drugs can aggravate them. 4) CO 2 : The use of CO 2 (0.2-1 l/min) mixed with O 2 (2l/min) during sleep has been studied, and showed decrease in the duration of CSR and improvement in SatO 2 , but decreased the quality of sleep and increased the sympathetic activity 29 . Additionally, the resulting hypercapnia increases the left and right ventricular post-load.…”