Treatment of Cheyne-Stokes respiration with nasal oxygen and carbon dioxide
European Respiratory Journal
Cheyne-Stokes respiration (CSR) during sleep is common in patients with severe congestive heart failure (CHF). It induces repetitive oxygen desaturations and impairs sleep [1, 2] . Disturbed sleep is likely to cause daytime symptoms and the repetitive oxygen desaturations and arousals increase sympathetic activity as well as right and left ventricular afterload  and may thus further impede left ventricular function and exercise tolerance    . Effective treatment for CSR is therefore
... or CSR is therefore needed. Nocturnal oxygen by nasal prongs reduces CSR by about 50% and consolidates sleep [1,    . Application of 3% CO 2 prevented CSR by increasing the arterial carbon dioxide tension (Pa,CO 2 ) above the apnoeic threshold  but sleep was adversely affected, this being attributed to the tight-fitting face mask used  . The hypothesis was tested that CO 2 in conjunction with O 2 given by nasal prongs is efficacious in the treatment of CSR. Plasma catecholamines were measured, to evaluate possible effects on sympathetic activity. Methods Subjects and protocol All patients with severe heart failure admitted to the department of cardiology were candidates for the study. Patients under the age of 75 yrs were eligible if they met the following criteria: at least one episode of cardiac decompensation, ejection fraction ð35%, stable condition on cardiac medication and evidence of CSR by nocturnal polysomnography. Exclusion criteria were myocardial infarction within 1 yr of entry, significant obstructive lung disease as defined by a forced expiratory volume in one second (FEV1)/forced vital capacity (FVC) <70%, primary valvular heart disease, tibial oedema or evidence of obstructive sleep apnoea (more than five obstructive apnoeas·h -1 ). Plasma catecholamines were evaluated in 15 healthy subjects (age 53.2±5.3 yrs) without significant sleep-disordered breathing. The study was approved by the local ethics committee. Informed written consent was obtained from all subjects. The study was designed as a single-blind, placebo-controlled trial. After an accommodation night where no treatment was applied the patients received air as well as O 2 plus CO 2 in a randomized, cross-over fashion on two consecutive nights. Polysomnography was performed during all three nights. Oxygen was given with a flow rate of 2 L·min -1 by nasal prongs and CO 2 was admixed simultaneously with a flow rate of 0.2-1 L·min -1 . Accordingly, the flow rate of the mixture was 2.2-3 L·min -1 . CO 2 flow rate was regulated depending on the transcutaneous carbon dioxide tension (Ptc,CO 2 ), which was not allowed to increase >7.3 kPa (55 mmHg) and on the occurrence of Treatment of Cheyne-Stokes respiration with nasal oxygen and carbon dioxide. S. Andreas, K. Weidel. G. Hagenah, S. Heindl. ©ERS Journals Ltd 1998. Abstract: Cheyne-Stokes respiration (CSR) is common in patients with congestive heart failure (CHF) and is associated with significant nocturnal O 2 desaturation, arousals and sympathetic activation. Nocturnal O 2 reduces CSR by only about 50%. More complete suppression of CSR may be achieved by adding CO 2 to O 2 . This study therefore aimed to evaluate the effects of nocturnal O 2 plus CO 2 on CSR, sleep and sympathetic activation. Nine patients with CHF (age 59±5 yrs; left ventricular ejection fraction 17.8±1.2% (mean±SEM) were studied in a cross-over, single-blind, placebo-controlled trial. After an accommodation night the patients were randomly assigned to one night each of O 2 plus CO 2 as well as air applied by nasal prongs. Nocturnal O 2 plus CO 2 reduced the duration of CSR as percentage of total sleep time (48.0±10 versus 7.4±2.0%; p=0.008) and increased arterial oxygen saturation (Sa,O 2 ) as well as mean transcutaneous carbon dioxide tension (Ptc,CO 2 ) (5.2±0.3 kPa (39±2 mmHg) versus 5.7±03 kPa (43±2 mmHg) p=0.011). Sleep did not improve and arousals were not reduced. Plasma noradrenaline was higher on the treatment night (486±116 versus 669±163 ng·L -1 ; p=0.035). In conclusion, nocturnal O 2 plus CO 2 improves Cheyne-Stokes respiration in patients with congestive heart failure but has adverse effects on the sequel of Cheyne-Stokes respiration, namely sympathetic activation. Eur Respir J 1998; 12: 414-419.