Quan Wei, Ding Ning, Dong Yanbin, Huang Mao, Zhang Xilong
Department of Respirology, First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, China.
Department of Respirology, First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, China. Email:
Zhonghua Yi Xue Za Zhi. 2014 Oct 21;94(38):2968-72.
To observe the efficacy of auto-trilevel positive airway pressure (Auto-trilevel PAP) ventilation in overlap syndrome (OS) patients with hypercapnia.
From October 2012 to May 2014, 21 OS patients with a PaCO2> 45 mmHg (1 mmHg = 0.133 kPa) and coexisting stable chronic obstructive pulmonary diseases (COPD) and moderate-to-severe OSAS were recruited. Three different positive airway pressure (PAP) modes of ventilators (SOMNOvent auto-S, Weinmann Inc, Germany) were employed for 8 hours per night with each mode at each night and two nights' interval without any treatment among different modes. Under mode one, the expiratory positive airway pressure (EPAP) issued by bilevel positive airway pressure (BiPAP) was titrated as the minimal positive pressure for a disappearance of snoring. The same inspiratory positive airway pressure (IPAP) titrated by end tidal CO2 levels under mode 1 was used under modes 2 and 3 as well. However, the EPAP issued by BiPAP under mode 2 was 3 cmH2O (1 cmH2O = 0.098 kPa) higher than that under mode 1. Under mode 3 with autotrilevel PAP, the beginning of EPAP was set the same as that under mode 1 while the end of EPAP (EEPAP) was automatically adjusted based on upper airway patency condition. Comparisons were made for parameters before and after treatment as well as among different ventilation modes. The following parameters were compared such as nocturnal apnea hypopnea index (AHI), minimal SpO2 (miniSpO2), arousal index, sleep efficiency, morning PaCO2 and Epworth sleepiness score (ESS).
Compared with the parameters pre-therapy, modes 1-3 showed a significant decrease in nocturnal AHI (6.3 ± 1.3), (3.1 ± 1.0), (3.6 ± 0.6) vs (38.6 ± 11.3) events/h), arousal index ((7.0 ± 1.1), (5.1 ± 0.9), (4.2 ± 1.7) vs (27.5 ± 5.4) events/h), morning PaCO2 (42.4 ± 3.8), (47.9 ± 2.6) and (43.2 ± 3.3) vs (57.3 ± 4.3) mmHg and daytime ESS (7.2 ± 1.3, 7.4 ± 1.3 and 5.3 ± 1.5 vs 11.4 ± 2.7), but a significant increase in nocturnal miniSpO2 (82.3 ± 5.4), (89.6 ± 3.9) and (90.3 ± 3.2) vs (62.4 ± 11.3) mmHg and sleep efficiency caused (71.3 ± 5.2)%, (79.4 ± 4.3)% and (83.2 ± 4.4)% vs (59.8 ± 6.3)% (all P < 0.01). Comparison of 3 modes demonstrated that, with the same IPAP, mode 3 resulted in the lowest arousal index, daytime ESS and the highest sleep efficiency. Comparison of modes 1 and 2 revealed a statistically lower AHI but higher miniSpO2 and morning PaCO2 under mode 2 (all P < 0.01). Compared with mode 1, mode 3 showed a lower AHI, higher miniSpO2 (all P < 0.01), but there was no significant difference in PaCO2 at the end of therapy. Compared with mode 2, mode 3 showed a significant lower PaCO2 (P < 0.01), but there was no significant difference in AHI and miniSpO2.
Auto-trilevel PAP ventilation is superior to fixed BiPAP ventilation in the treatment of hypercapnic OS since this novel PAP mode can achieve a higher efficacy in simultaneous removal of residual apnea hypopnea events and correction of hypercapnia and yield a higher sleep quality and lower daytime sleepiness.
观察自动三水平气道正压通气（Auto-trilevel PAP）对重叠综合征（OS）合并高碳酸血症患者的疗效。
选取2012年10月至2014年5月期间收治的21例PaCO2>45 mmHg（1 mmHg = 0.133 kPa）、并存稳定慢性阻塞性肺疾病（COPD）及中重度阻塞性睡眠呼吸暂停低通气综合征（OSAS）的OS患者。采用三种不同的气道正压（PAP）通气模式（德国伟曼公司SOMNOvent auto-S型呼吸机），每晚使用8小时，每种模式各使用一晚，不同模式之间间隔两晚不进行任何治疗。模式一：双水平气道正压通气（BiPAP）的呼气末正压（EPAP）滴定至鼾声消失时的最小正压。模式二和模式三下的吸气末正压（IPAP）与模式一下根据呼气末二氧化碳水平滴定的相同。然而，模式二下BiPAP发出的EPAP比模式一高3 cmH2O（1 cmH2O = 0.098 kPa）。模式三采用自动三水平气道正压通气，EPAP起始值与模式一相同，而EPAP终末值（EEPAP）根据上气道通畅情况自动调整。比较治疗前后及不同通气模式下的参数。比较夜间呼吸暂停低通气指数（AHI）、最低血氧饱和度（miniSpO2）、觉醒指数、睡眠效率、晨起PaCO2及爱泼沃斯嗜睡量表（ESS）评分等参数。
与治疗前相比，模式一至模式三下夜间AHI显著降低（6.3±1.3、3.1±1.0、3.6±0.6比38.6±11.3次/小时）、觉醒指数（7.0±1.1、5.1±0.9、4.2±1.7比27.5±5.4次/小时）、晨起PaCO2（42.4±3.8、47.9±2.6、43.2±3.3比57.3±4.3 mmHg）及日间ESS（7.2±1.3、7.4±1.3、5.3±1.5比11.4±2.7），夜间miniSpO2显著升高（82.3±5.4、89.6±3.9、90.3±3.2比62.4±11.3 mmHg）及睡眠效率提高（71.3±5.2%、79.4±4.3%、83.2±4.4%比59.8±6.3%）（均P<0.01）。三种模式比较显示，在相同IPAP情况下，模式三的觉醒指数、日间ESS最低，睡眠效率最高。模式一与模式二比较显示，模式二的AHI在统计学上更低，但miniSpO2及晨起PaCO2更高（均P<0.01）。与模式一相比，模式三的AHI更低，miniSpO2更高（均P<0.01），但治疗结束时PaCO2无显著差异。与模式二相比，模式三的PaCO2显著更低（P<0.01），但AHI及miniSpO2无显著差异。
自动三水平气道正压通气在治疗合并高碳酸血症的OS方面优于固定双水平气道正压通气，因为这种新型PAP模式在同时消除残余呼吸暂停低通气事件及纠正高碳酸血症方面能取得更高疗效，提高睡眠质量，降低日间嗜睡程度。
