Effect of ventilation modalities on the early prognosis of patients with poststroke sleep apnea

Abstract

Objective: Continuous positive airway pressure (CPAP) is the primary modality for treating sleep apnea after acute ischemic stroke (AIS). However, not all patients are well adherent to CPAP. Finding an alternative modality of ventilation to CPAP is essential.

Methods: This prospective randomized clinical trial was conducted from 1 May 2022 to 8 January 2023 at the Department of Neurology, Wuhan Union Hospital. Participants diagnosed with sleep apnea after AIS were grouped according to block randomization principles into the usual care group (nasal cannula and facemask), nasal continuous positive airway pressure (nCPAP) group, and high-flow nasal cannula (HFNC) group. Rates of pulmonary infection and endotracheal intubation within 1 week of hospitalization and 28-day mortality (poststroke) were the primary outcomes (early prognosis).

Results: In the trial, 178 patients (119 males [66.85%]; mean [SD] age, 61.04 [11.78] years) were eventually enrolled in the usual care group (n = 63), the nCPAP group (n = 55), and the HFNC group (n = 60). After ventilation, the nCPAP and HFNC groups were more effective than the usual care group in reducing the rate of pulmonary infection, endotracheal intubation, and improving neurological function and sleep apnea severity. However, there was no difference in 28-day mortality. Additionally, the improvement in prognosis was consistent between nCPAP and HFNC. In the comparison of comfort, the HFNC group was superior to nCPAP.

Interpretation: nCPAP and HFNC reduced early pulmonary infection rates and endotracheal intubation rates. For patients with poor compliance with nCPAP, HFNC may be the best alternative.

Figure 1

Flow chart of the study.

Figure 2

Comparison of the early prognosis of patients with sleep apnea after acute ischemic stroke with different modalities of ventilation. (A) Comparison of early prognosis in different ventilation modalities. (B) Change in 28‐day mortality rate over time. (C) Change in endotracheal intubation rate over time. (D) Change in pulmonary infection rate over time. ***p < 0.001; ^# p > 0.05.

Figure 3

Multivariate risk factor analysis of pulmonary infection, endotracheal intubation and 28‐day mortality. APACHE II score, acute physiology and chronic health evaluation II score; BMI, body mass index; HFNC, high‐flow nasal cannula; nCPAP, nasal continuous positive airway pressure; NIHSS, national institutes of health stroke scale; NLR, neutrophil‐to‐lymphocyte ratio; SCSS, semiquantitative cough strength score; WBC, white blood cell.

Figure 4

Comparison of comfort scores and duration of ventilation in different ventilation modalities. (A) Discomfort related to the interface. (B) Discomfort related to airway's dryness. (C) Average daily ventilation duration. *p < 0.05; **p < 0.01; ***p < 0.001.