Chest
Volume 140, Issue 4, October 2011, Pages 939-945
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Original Research
Critical Care
Noninvasive Ventilation in COPD: Impact of Inspiratory Pressure Levels on Sleep Quality

https://doi.org/10.1378/chest.11-0253Get rights and content

Background

Although high-intensity noninvasive positive pressure ventilation (HI-NPPV) is superior to low-intensity noninvasive positive pressure ventilation (LI-NPPV) in controlling nocturnal hypoventilation in stable hypercapnic patients with COPD, it produces higher amounts of air leakage, which, in turn, could impair sleep quality. Therefore, the present study assessed the difference in sleep quality during HI-NPPV and LI-NPPV.

Methods

A randomized, controlled, crossover trial comparing sleep quality during HI-NPPV (mean inspiratory positive airway pressure 29 ± 4 mbar) and LI-NPPV (mean inspiratory positive airway pressure 14 mbar) was performed in 17 stable hypercapnic patients with COPD who were already familiar with HI-NPPV.

Results

Thirteen patients (mean FEV1 27% ± 11% predicted) completed the trial; four patients refused to sleep under LI-NPPV. There was no significant difference in sleep quality between the treatment groups (all P > .05), with a mean difference of −3.0% (95% CI, −10.0 to 3.9; P = .36) in the primary outcome, namely non-rapid eye movement sleep stages 3 and 4. However, nocturnal Paco2 was lower during HI-NPPV compared with LI-NPPV, with a mean difference of −6.4 mm Hg (95% CI, −10.9 to −1.8; P = .01).

Conclusions

In patients with COPD, high inspiratory pressures used with long-term HI-NPPV produce acceptable sleep quality that is no worse than that produced by lower inspiratory pressures, which are more traditionally applied in conjunction with LI-NPPV. In addition, higher pressures are more successful in maintaining sufficient alveolar ventilation compared with low pressures. Thus, HI-NPPV is a very promising new approach, but still requires large, longer-term trials to determine the impact on outcomes such as exacerbation rates and longevity.

Trial registry

German Clinical Trials Register (DRKS); No.: DRKS00000520; URL: www.drks.de

Section snippets

Materials and Methods

The study protocol was approved by the Ethics Committee at the Albert-Ludwigs University, Freiburg, Germany, and was performed in accordance with the ethical standards laid down in the Declaration of Helsinki. Informed, written consent was obtained from all subjects.

Results

Seventeen patients were consecutively enrolled in the study. Four patients dropped out (Fig 1). One patient in period one and three patients in period two refused to sleep under LI-NPPV because of fear of asphyxia. Data are presented for the full analysis set consisting of the 13 patients who completed both treatments in the crossover setting. Demographic data, ventilator settings for HI-NPPV, lung function parameters, and daytime blood gases with supplemental oxygen are shown in Table 1. Mean

Discussion

This is the first randomized crossover trial, to our knowledge, to compare the effects of different forms of NPPV (HI-NPPV vs LI-NPPV) on sleep quality in patients with chronic hypercapnic respiratory failure due to COPD. Two main findings are reported and discussed.

First, sleep quality was comparable between HI-NPPV and LI-NPPV. This also pertained to arousals, suggesting that a reduction in IPAP does not result in an improvement in sleep quality. Although the most recently published trial

Acknowledgments

Author contributions: Dr Dreher: contributed to the planning, data collection, data analysis, and writing of the manuscript.

Dr Ekkernkamp: contributed to the data collection and writing of the manuscript.

Dr Walterspacher: contributed to the data collection and writing of the manuscript.

Dr Walker: contributed to the data collection and writing of the manuscript.

Dr Schmoor: contributed to the statistical analysis of the data and writing of the manuscript.

Dr Storre: contributed to the data

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  • Cited by (0)

    Drs Storre and Windisch contributed equally to this work.

    Funding/Support: The study was supported by the German Interdisciplinary Society of Home Mechanical Ventilation (Deutsche Interdisziplinäre Gesellschaft für Außerklinische Beatmung, DIGAB). The study group received an open research grant from Breas Medical AB (Molnlycke, Sweden), Respironics Inc (Pittsburgh, PA), and ResMed GmbH and Co KG (Germany).

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

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