Piper A J, Sullivan C E
Sleep Disorders Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
Chest. 1994 Feb;105(2):434-40. doi: 10.1378/chest.105.2.434.
Although nasal continuous positive airway pressure (CPAP) is effective in the treatment of most patients with obstructive sleep apnea (OSA), there is a small group of such patients in whom rapid eye movement (REM) hypoventilation and CO2 retention persist despite the use of CPAP and supplemental oxygen. In this report we describe our experience with nocturnal nasal ventilation (nocturnal nasal positive pressure ventilation [NIPPV] in such patients and its effectiveness in reversing daytime hypercapnia. Thirteen patients, aged 28 to 69 years, with severe OSA confirmed on polysomnography, failed to respond to initial CPAP therapy. All were grossly obese (body mass index [BMI] > 35 kg.ml-1) and hypercapnic (mean PaCO2, 62 mm Hg). Nocturnal nasal ventilation was commenced using a volume-cycled ventilator, which was well tolerated in all patients. After 7 to 18 days of NIPPV, significant improvements in daytime arterial blood gas values were achieved, with a rise in arterial oxygen tension from 50 +/- 2.6 (SEM) to 66 +/- 3 mm Hg (p < 0.001) and a fall in CO2 from 62 +/- 2.5 to 46 +/- 1 mm Hg (p < 0.0001). Nine of the 13 patients were able to be established on a regimen of nasal CPAP after this period, while 3 patients required a longer period (up to 3 months) before adequate nocturnal ventilation could be maintained. In one patient, the improvements in ventilatory drive achieved with NIPPV could not be maintained on CPAP, and she was transferred on to NIPPV long term. These results indicate that effective nasal ventilation leads to an overall improvement in spontaneous ventilation and blood gas values both awake and asleep. We believe this improvement is the result of improved central ventilatory drive. Short-term NIPPV provides lasting benefits allowing the majority of such patients to resume CPAP therapy. Short-term intervention with this therapy should be considered as an interim measure in patients with severe hypercapnic OSA who fail to respond to initial CPAP therapy.
尽管鼻持续气道正压通气（CPAP）对大多数阻塞性睡眠呼吸暂停（OSA）患者有效，但仍有一小部分此类患者，尽管使用了CPAP和补充氧气，快速眼动（REM）低通气和二氧化碳潴留仍持续存在。在本报告中，我们描述了我们在此类患者中进行夜间鼻通气（夜间鼻正压通气[NIPPV]）的经验及其逆转白天高碳酸血症的有效性。13例年龄在28至69岁之间的患者，经多导睡眠图证实患有严重OSA，对初始CPAP治疗无反应。所有患者均严重肥胖（体重指数[BMI]>35kg/ml-1）且有高碳酸血症（平均动脉血二氧化碳分压[PaCO2]为62mmHg）。使用容量控制通气机开始夜间鼻通气，所有患者对此耐受性良好。在进行NIPPV 7至18天后，白天动脉血气值有显著改善，动脉血氧分压从50±2.6（标准误）升至66±3mmHg（p<0.001），二氧化碳分压从62±2.5降至46±1mmHg（p<0.0001）。在此期间后，13例患者中有9例能够建立鼻CPAP治疗方案，而3例患者需要更长时间（长达3个月）才能维持足够的夜间通气。在1例患者中，NIPPV实现的通气驱动力改善在CPAP上无法维持，她被转为长期使用NIPPV。这些结果表明，有效的鼻通气可使清醒和睡眠时的自主通气和血气值总体改善。我们认为这种改善是中枢通气驱动力改善的结果。短期NIPPV可提供持久益处，使大多数此类患者能够恢复CPAP治疗。对于初始CPAP治疗无反应的严重高碳酸血症OSA患者，应考虑将这种治疗的短期干预作为一种临时措施。
