Adaptive pressure support servoventilation: a novel treatment for sleep apnea associated with use of opioids

Abstract

Rationale: Opioids have become part of contemporary treatment in the management of chronic pain. However, chronic use of opioids has been associated with high prevalence of sleep apnea which could contribute to morbidity and mortality of such patients.

Objectives: The main aim of this study was to treat sleep apnea in patients on chronic opioids.

Methods: Five consecutive patients who were referred for evaluation of obstructive sleep apnea underwent polysomnography followed by a second night therapy with continuous positive airway pressure (CPAP) device. Because CPAP proved ineffective, patients underwent a third night therapy with adaptive pressure support servoventilation.

Main results: The average age of the patients was 51 years. They were habitual snorers with excessive daytime sleepiness. Four suffered from chronic low back pain and one had trigeminal neuralgia. They were on opioids for 2 to 5 years before sleep apnea was diagnosed. The average apnea-hypopnea index was 70/hr. With CPAP therapy, the apnea-hypopnea index decreased to 55/hr, while the central apnea index increased from 26 to 37/hr. The patients then underwent titration with adaptive pressure support servoventilation. At final pressure, the hypopnea index was 13/hr, with central and obstructive apnea index of 0 per hour.

Conclusions: Opioids may cause severe sleep apnea syndrome. Acute treatment with CPAP eliminates obstructive apneas but increases central apneas. Adaptive pressure support servoventilation proves to be effective in the treatment of sleep related breathing disorders in patients on chronic opioids. Long-term studies on a large number of patients are necessary to determine if treatment of sleep apnea improves quality of life, decreases daytime sleepiness, and ultimately decreases the likelihood of unexpected death of patients on opioids.

Figure 1

A 10-min epoch of polysomnogram showing obstructive and central apneas, and hypopneas. Note fluctuations in SpO₂, which parallel apneas and hypopneas. Arousals coincide with resumption of breathing after an apnea and are characterized by changes (elevations) in EEG and eye and leg movements.

Figure 2

The same patient on CPAP at pressure of 10 cm H₂O. There are many central apneas associated with arousals.

Figure 3

The same patient on adaptive pressure support servoventilation. Note uninterrupted breathing without any central or obstructive disordered breathing events.

Figure 4

Mean values for various sleep disordered breathing events at final continuous positive airway pressure (CPAP) and adaptive pressure support servoventilation (APSSV). Note the reduction in apnea-hypopnea index (AHI) and elimination of central apneas with APSSV.