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The use of nasal high-flow therapy to treat central sleep apnoea in patients with congestive heart failure

Leest, S. van der (2018) The use of nasal high-flow therapy to treat central sleep apnoea in patients with congestive heart failure.

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Abstract:Introduction: Central sleep apnoea (CSA) is a common syndrome in patients with congestive heart failure. The combination of CSA and congestive heart failure is associated with higher morbidity and mortality rates. However, there is no safe and effective therapy available for treating CSA in these patients. Nasal high-flow therapy (nHFT) is a novel therapy that provides high levels of flow ranging between 10-50 L/min of heated and humidified air through an open nasal cannula, with or without oxygen. The aim of the study is to evaluate the effectiveness of nHFT stabilising ventilation in patients with congestive heart failure and CSA. Methods: Ten patients with severe congestive heart failure and untreated moderate to severe CSA will be treated with nHFT during the night for 4 weeks. The apnoea hypopnoea index (AHI) before and after nHFT is compared. The patients will be initiated on nHFT during a titration night, in which different nHFT settings, with and without oxygen, are applied. Many physiological effects of nHFT, such as the generated pressure, work of breathing, neural breathing drive and heart rate variability (HRV), will be measured to determine the optimal nHFT setting and gain more information about the mechanisms of action. Results: Currently, the study is on-going. So far, three patients have been included. Preliminary results showed low compliance rates: 2 patients dropped-out due to non-tolerance, and the only patient who has finished the study, did not decide to continue therapy afterwards. Complaints included nose irritation, a too large nasal cannula, and an uncomfortable high flow rate. The AHI of the patient who finished the study decreased from 30 to 12 events per hour with nHFT. During the titration night, the AHI was lower when additional oxygen was given. When the nHFT flow rate was higher, an increase of the pharyngeal pressure was not measured, the work of breathing decreased when the patient slept with the mouth closed, and the neural breathing drive seemed to decrease. nHFT did not influence HRV. Discussion: There are indications that nHFT with the addition of oxygen makes ventilation more stable in patients with congestive heart failure and CSA. Especially oxygen addition seems to be effective reducing AHI. More patients need to be included in the study to verify this result. Patients were not satisfied with nHFT. Probably, low humidity levels and a large nasal cannula might explain the low compliance. A humidity level between 34-37 ◦DP and a smaller nasal cannula are advised. Furthermore, the high flow rate made exhaling more difficult, which is uncomfortable. It is recommended to analyse whether a nHFT device, in which the flow rate decreases when there is resistance, would increase the compliance. Moreover, it was difficult to determine the optimal nHFT setting during the titration night due to poor sleep quality. The sleep quality during the titration night and compliance might increase when patients get used to sleeping with the nHFT device one week before the titration night. The pharyngeal pressure was not measured properly due to occlusion of the catheter by secretions. When occlusion by secretions was prevented, the pharyngeal pressure increased linearly with a higher nHFT flow rate. A 20 ml/h airflow produced by a microinfusor at the inlet of the catheter might avoid occlusion of the catheter by secretions. There are indications that a higher flow rate reduces the work of breathing and the neural breathing drive, which indicates that patients can relax their muscles more with a higher flow rate. No clear HRV changes due to nHFT were found, since the sleep stages influenced HRV a lot. HRV should be compared before and after nHFT to analyse HRV changes due to nHFT. Conclusion: nHFT with the addition of oxygen might stabilise ventilation in patients with congestive heart failure and CSA. However, due to the poor compliance so far, nHFT does not seem to be an optimal treatment for these patients.
Item Type:Essay (Master)
Faculty:TNW: Science and Technology
Subject:44 medicine
Programme:Technical Medicine MSc (60033)
Awards:Avril McDonald Prize, 2018
Link to this item:http://purl.utwente.nl/essays/74404
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