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中枢性通气功能障碍诊治指南

已有 1952 次阅读 2017-6-13 13:25 |个人分类:临床指南和病例解析|系统分类:观点评述| style, color

中枢性通气功能障碍诊治指南

中枢性通气功能障碍诊治指南

Statement
1) describe abnormal breathing patterns of central origin appearing in a periodic fashion as “periodic breathing with or without apnoea”;
2) describe the polysomnographic pattern of waxing and waning of the airflow and effort with or without apnoeas as “periodic breathing”, independent of its origin (e.g. cardiovascular disorders, high altitude or opioid intake); and
3) acknowledge that the term CSB has historically been used to describe periodic breathing with apnoeas in the context of heart failure or stroke, but replace the term CSB with “periodic breathing with apnoea in the setting of heart failure (or another underlying disease)”.

Statements
1) Evidence shows that the nasal cannula is the best validated surrogate for hypopnoea detection for its good frequency response, while thermistor, which analyses the oronasal flow, is the recommended sensor for detection of apnoeas (A).
2) Evidence shows that RIP can be reliably used to classify respiratory events in a routine setting.Oesophageal manometry is used in selected research protocols (A).
3) Central hypopnoeas are very difficult to score. They are defined as the proportional diminution in both naso-oral flow and respiratory effort in absence of specific characteristics of an obstructive hypopnoea: inspiratory flow flattening shape, thoracoabdominal paradox and snoring (A). For definite differentiation of central and obstructive hypopnoeas, PSG may be required (detection of sleep–wake transition, and differentiation of rapid eye movement (REM) and non-rapid eye movement (NREM) sleep) (A).
4) There is a need for novel and simple devices and sensors for sleep diagnosis to allow straightforward
and cost-effective diagnostic approaches, and thus reach a larger population.
5) The daytime hallmark feature of hypoventilation is diurnal hypercapnia. To find these patients, a series of daytime tests are useful: FVC <50% and venous bicarbonate >27 mmol (A).
6) Evidence suggests that classical PSG sensors together with measurement of PaCO2 and oesophageal pressure are the optimal way to assess nighttime hypoventilation. Instead of PaCO2 and intrathoracic pressure, which are invasive techniques, surrogates are used. PaCO2 can be estimated by transcutaneous carbon dioxide and end-tidal carbon dioxide (A). Oesophageal pressure can be evaluated by thoracoabdominal bands, flow limitation, EMG of the thoracic muscles or PTT (A).
During noninvasive ventilation (NIV) titration, more sensors are required: minute ventilation measurement,pressures, leak sensors and procedures to detect asynchronies (the latter two are the most likely problems to occur during NIV) (A).

Statements
1) Opioids may, in a dose-dependent manner, induce CSA dominated by hypoxaemia during sleep (B).
2) Most data suggest that both ASV and bilevel positive airway therapy are superior to conventional CPAP for elimination of opioid-associated CSA (B).

Statements
1) Healthy lowlanders travelling to altitudes >1600 m may experience CSA, which is termed HAPB in this setting. The severity of CSA/HAPB increases with increasing altitude (B).
2) Patients with OSAS living near sea level may show exacerbation of breathing disturbances in the first few days at altitude.
3) The evidence suggests that oxygen-enriched air or ACT reduces CSA/HAPB and improves nocturnal oxygen saturation in healthy lowlanders staying at altitude (B).
4) Combined treatment with ACT and automatic positive airway pressure (APAP) is an appropriate treatment in this setting as it prevents central apnoeas and improves nocturnal oxygen saturation compared to APAP alone (B).

Statements
1) CSA is a common comorbidity of HFrEF and HFpEF (A).
2) The severity of CSA is related to the severity of HFrEF and HFpEF (C).

Statements
1) In HFrEF, there is an association between the presence of CSA and an increased risk of ventricular arrhythmias (C).
2) In HFrEF, the presence of CSA is associated with an increased risk of death (B).

Statements
1) Evidence shows that optimal cardiac treatment of HFrEF may improve CSA (C).
2) Evidence suggests that HFrEF patients with CSA can be treated with CPAP, if CPAP suppresses CSA and improves symptoms (C).
3) In heart failure and symptomatic CSA, the members of the Task Force perform a trial of CPAP (C).
However, if CPAP does not suppress CSA, they do not continue it for prolonged periods.
4) ASV normalises the AHI in patients with CHF and CSA more effectively compared to CPAP therapy and nocturnal oxygen (A).
5) Based upon the available information at this time, members of the Task Force stop prescribing ASV to treat CSA in patients with stable HFrEF with LVEF ⩽45% (B).
6) Before starting a patient with CSA on ASV, the members of the Task Force assess for the presence of HFrEF with an LVEF ⩽45% to see if they are in the higher risk group (C).
7) The members of the Task Force use BPAP-ST, ACT and theophylline only in normo/hypocapnic CSA related to HFrEF, if adequate trials of indicated therapies fail (C).

Statement
Evidence shows that CSA is often present in patients after stroke but the prognostic significance of CSA in these patients is still uncertain (C).

Statements
1) The prevalence of CSA is low in patients with acromegaly and related to disease activity. In diabetes mellitus, OSA is the dominant type of SDB. In ESRD, CSA prevalence is dependent on dialysis procedures and fluid shift during the night (B).
2) The members of the Task Force treat clinically significant CSA in acromegaly, diabetes mellitus and ESRD with CPAP or ASV (C).

Statements
1) There is very little evidence on the prevalence and prognostic relevance of CSA and hypoventilation syndromes in ILD patients (D).
2) There is only little evidence on the beneficial effects of oxygen supplementation in case of nocturnal hypoxaemia. Elevated respiratory rate, respiratory minute volume and heart rate are reduced by oxygen supplementation (C).

Statements
1) There is limited evidence suggesting that the prevalence of central apnoeas and periodic breathing is increased in pulmonary hypertension (B).
2) The Task Force members usually screen patients with pulmonary hypertension by cardiorespiratory sleep studies (B).
3) The pathophysiological effect of SDB and the impact of treatment are unclear in these patients (B).
4) Preliminary evidence suggests that both nocturnal supplemental oxygen and ACT may improve nocturnal oxygenation and periodic breathing in precapillary pulmonary hypertension (B).

Statements
1) The members of the Task Force use the term treatment-persistent CSA for patients with CSA newly developing under treatment with CPAP or BPAP and persisting under continuous use (A).
2) They describe the combination of OSA with any phenotype of central disturbances or hypoventilation as “co-existing OSA and CSA (or CSB or hypoventilation)” (D).
3) They do not use the diagnosis of treatment-emergent CSA for CSA in patients with underlying cardiovascular, endocrine, renal or neurological diseases, or for pre-existing CSA prior to initiation of PAP and transient CSA (A).
4) Evidence suggests that avoidable causes of CSA under PAP may include excessive titration,post-hyperventilation apnoea, post-arousal apnoea, overestimation due to split-night error and misclassification of central hypopnoeas (C).
5) ASV has been shown to more effectively improve treatment-persistent CSA compared to oxygen, CPAP, BPAP-ST and NIV (B).

Statements
1) Evidence on the epidemiology, pathophysiology and outcome of ICSA is limited (D).
2) The members of the Task Force perform treatment trials with zolpidem or ACT only in symptomatic patients under close supervision (D).
3) CPAP or ASV may be considered in individual symptomatic cases (D).

Statements
Evidence shows that:
1) hypoventilation is typically the result of increased mechanical load to breathing and decreased ventilatory drive/response, which frequently interact (A);
2) obesity is the most prevalent factor contributing to hypoventilation by means of increased mechanical load (A);
3) hypoventilation may co-exist with sleep apnoea, since pathophysiological factors such as obesity and central respiratory insufficiency are frequently shared (A);
4) central hypoventilation is a rare form of hypoventilation, which may be congenital as a result of deficiency of the PHOX2B gene (A); and
5) NMDs may result in hypoventilation as a consequence of respiratory muscle insufficiency and/or dysfunction (A).

Statements
1) Alveolar hypoventilation is frequently present in several NMDs, including ALS, DMD, myotonic dystrophy and AMD (A).
2) NIV improves survival in ALS (B) and DMD (C).
3) NIV can improve gas exchange and symptoms in NMD (B).
4) NIV improves QoL in ALS and DMD (B).
5) 24 h NIV is a treatment option in NMD when diurnal hypoventilation develops (B).

Statements
In kyphoscoliotic patients, the evidence shows that:
1) hypoventilation is the major SDB event (A); and
2) NIV with or without LTOT is the first treatment option (B).

Statements
1) Most Task Force members screen obese patients for OHS by sampling of blood gases (B), nocturnal transcutaneous PCO2 and/or determination of serum bicarbonate during wakefulness (C).
2) Increases in PaCO2 or capillary PCO2, or marked elevations of transcutaneous PCO2 (as compared to baseline) during REM sleep indicate OHS (B).
3) CPAP failure is higher in OHS as compared to OSAS (B).
4) NIV during sleep improves hypoventilation, sleep, QoL and survival. NIV is superior to lifestyle counselling (B).
5) OHS is associated with impaired ventilatory responses to hypercapnia and hypoxia, and increased cardiometabolic morbidity, which can be improved under NIV (B).
6) NIV with pressure support and target volume ventilation are both effective. Comparative studies do not show superiority of one mode (B).
7) Adherence of >4 h per day to NIV is crucial for improving hypercapnia (B).
8) Monotherapy with oxygen reduces ventilation and increases hypercapnia. Oxygen should only be applied as an adjunct to NIV (B).
9) Bariatric surgery reduces body weight, improves lung function and normalises blood gases (C).

Statement
Evidence suggests that nocturnal NIV in stable hypercapnic COPD may improve survival and QoL andthat inspiratory pressures need to be adjusted to levels high enough to improve ventilation (C).

Statement
There is currently insufficient evidence to support the use of home nocturnal NIV in patients with prolonged hypercapnia after a COPD exacerbation with AHRF (B).