Georg Nilius

Background: Obstructive sleep apnea (OSA) is a highly prevalent condition; however, the majority of patients remain undiagnosed. There is a potential to expand the diagnostic capacity of sleep laboratories. The study objective was to validate a portable respiratory monitoring device (Alice PDX) against polysomnography (PSG) in the laboratory and to assess its reliability at home. Methods: A total of 85 patients with suspected OSA (80% male, mean age 49.1±13.5 years, body mass index 29.7±6.9 kg/m², Epworth Sleepiness Scale 10.0±5.1) were randomized to 3 diagnostic nights: 1 night simultaneous in-laboratory PSG and PDX recording; 1 night self-applied PDX at home, and 1 night in-laboratory PSG. Study data were manually scored according to American Academy of Sleep Medicine criteria. Results: The Alice PDX was in diagnostic agreement with simultaneously recorded reference PSG in 96.4% of studies. In 2.4% of studies the in-laboratory PDX underestimated and in 1.2% of studies it overestimated the apnea hypopnea index (AHI). The difference between the AHI from the reference PSG and the home study was similar to the difference between the PSGs (2.79 vs 0.79, p=0.08). Conclusion: In a population with a high suspicion of OSA, the Alice PDX showed a high level of diagnostic agreement with a simultaneous PSG and performed valid home diagnostic studies for OSA. If manually scored, the portable device can be used by sleep specialists for diagnosing moderate-to-severe obstructive sleep apnea in cases with a high pretest probability for the disease over a wide range of disease severity. The technology can be deployed reliably outside of the sleep laboratory setting.

Background: COPD patients who develop chronic hypercapnic respiratory failure have a poor prognosis. Treatment of choice, especially the best form of ventilation, is not well known. Objectives: This study compared the effects of pressure-controlled (spontaneous timed [ST]) non-invasive ventilation (NIV) and NIV with intelligent volume-assured pressure support (IVAPS) in chronic hypercapnic COPD patients regarding the effects on alveolar ventilation, adverse patient/ventilator interactions and sleep quality. Methods: This prospective, single-center, crossover study randomized patients to one night of NIV using ST then one night with the IVAPS function activated, or vice versa. Patients were monitored using polysomnography (PSG) and transcutaneous carbon dioxide pressure (PtcCO₂) measurement. Patients rated their subjective experience (total score, 0–45; lower scores indicate better acceptability). Results: Fourteen patients were included (4 females, age 59.4±8.9 years). The total number of respiratory events was low, and similar under pressure-controlled (5.4±6.7) and IVAPS (8.3±10.2) conditions (P=0.064). There were also no clinically relevant differences in PtcCO₂ between pressure-controlled and IVAPS NIV (52.9±6.2 versus 49.1±6.4 mmHg). Respiratory rate was lower under IVAPS overall; between-group differences reached statistical significance during wakefulness and non-rapid eye movement sleep. Ventilation pressures were 2.6 cmH₂O higher under IVAPS versus pressure-controlled ventilation, resulting in a 20.1 mL increase in breathing volume. Sleep efficiency was slightly higher under pressure-controlled ventilation versus IVAPS. Respiratory arousals were uncommon (24.4/h [pressure-controlled] versus 25.4/h [IVAPS]). Overall patient assessment scores were similar, although there was a trend toward less discomfort during IVAPS. Conclusion: Our results show that IVAPS NIV allows application of higher nocturnal ventilation pressures versus ST without affecting sleep quality or inducing ventilation-associated events.

Bei zunehmender Adipositas finden sich erheblich höhere Prävalenzen von obstruktiver Schlafapnoe und Hypoventilationssyndromen. Die internationalen Empfehlungen definieren das Obesitas-Hypoventilationssyndrom (OHS) bei Patienten mit einem BMI >30kg/m², die eine Hyperkapnie am Tage (PaCO₂ >45 mmHg) aufweisen, ohne dass diese durch andere Erkrankungen (wie z.B. eine COPD oder neuromuskuläre Erkrankungen) zu erklären ist.

Increasingly frequent, it is clinically indicated to obtain tissue from a peripheral lung lesion (PLL) to yield a pathological diagnosis. The aim of the present study was to evaluate the diagnostic sensitivity of transbronchial needle aspiration (TBNA) and transbronchial catheter aspiration (TBCA) in addition to transbronchial forceps biopsy (TBB) at conventional bronchoscopy. Eligible patients showing a PLL on computed tomography scans were included in the study. In all patients, following TBB, TBNA and TBCA were employed in randomised order under fluoroscopy. Fourty-eight patients were enrolled, of whom 46 patients with 46 PLLs were included in the analysis. The mean ± SD diameter of the PLL was 27.0 ± 13.3 mm. The overall sensitivity for all modalities was 69.6 %; PLL ≤20 or >20 and ≤30 mm in diameter showed a sensitivity of 60.0 and 72.2 %, respectively. For malignant PLL (n = 33), the combined sensitivity of TBNA + TBCA versus TBB was significantly higher (63.6 vs. 33.3 %, p ≤ 0.05), and could not further be improved by TBB. For benign PLL, TBB was superior to TBNA + TBCA (76.9 vs. 38.5 %). TBB, TBNA and TBCA are complementary to one another. Combining the three techniques, even allows transbronchial specimen collection of PLL <3 cm in diameter at conventional bronchoscopy.

Positive airway pressure (PAP) therapy adherence can be affected by rhinitis sicca and xerostomia complaints. Additional heated humidification (HH) is the appropriate method when such complaints arise. The aim of this study was to determine if HH with a supplementary heated breathing tube can increase adherence, reduce subjective nasopharyngeal complaints (NPC), and improve sleepiness (ESS: Epworth Sleepiness Scale) and quality of life (FOSQ: Functional Outcome of Sleep Questionnaire). We subdivided 72 obstructive sleep apnea (OSA) patients into two groups before therapy initiation. The NPC risk group consists of subjects with NPC and the low-risk group without. The risk group was identified by a score of >9 in a 5-item 25-point NPC questionnaire and pathological ESS. All patients were eligible for automatic CPAP devices (APAP), which were randomly configured with or without HH during 6 weeks. The adherence differences with and without HH were not significant in the NPC risk group (330 ± 103 vs. 281 ± 118 min/night) and in the low-risk group (330 ± 116 vs. 321 ± 89). NPC and ESS scores in the risk group were both significantly reduced with HH. Daily function (FOSQ) in the risk group was significantly improved with HH (90.0 ± 11.9 vs. 82.0 ± 12.0 (p < 0.05)). HH showed a tendency to improve APAP adherence. The adherence in both groups was quite high, and for that reason, it is difficult to show a statistically significant effect. A differentiation into NPC risk groups before starting PAP treatment is useful. HH reduces side effects and sleepiness and improves quality of life in an NPC risk group.

Immer wieder kommt es vor, dass Patienten zur stationären Aufnahme private Geräte mitbringen, die sie dringend benötigen – z. B. einen Insulin-Pen oder ein CPAP-Gerät. Manche Kliniken gestatten den Gebrauch dieser Geräte nicht. Die Begründung: Das Personal sei nicht eingewiesen, und zudem sei unklar, ob das Gerät überhaupt sicher sei. Dieses Positionspapier stellt den aktuellen juristischen Hintergrund dar und kommentiert die Situation aus ärztlicher Sicht.