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Thematic Poster Session

M ONDAY, S EPTEMBER 4 TH 2006

Hall B2-6 - 12:50-14:40

230. Continuous positive airflow pressure (CPAP) therapy

P2401 Cost/efficacy in alternative methods of titrating CPAP Juan F. Masa 1 , Antonio Jimenez 2 , Joaquin Duran 3 , Francisco Capote 4 , Carmen Monasterio 5 , Mercedes Mayos 6 , Joaquin Teran 7 , Lourdes Hernandez 8 , Ferran Barbe 9 , Manuela Rubio 1 , Jose M. Montserrat 8 . 1 Respiratory Service, San Pedro de Alcantara Hospital, Caceres, Spain; 2 Respiratory Service, Valdecilla Hospital, Santander, Spain; 3 Pulmonary Service, Txagorritxu Hospital, Vitoria, Spain; 4 Pulmonary Service, Virgen del Rocio Hospital, Sevilla, Spain; 5 Pulmonary Service, Bellvitge Hospital, Barcelona, Spain; 6 Pulmonary Service, San Pau Hospital, Barcelona, Spain; 7 Pulmonary Service, General Yague Hospital, Burgos, Spain; 8 Pulmonary Service, Clinic Hospital, Barcelona, Spain; 9 Pulmonary Service, Vilanova Hospital, Lleida, Spain Introduction: Polysomnographic CPAP titration consumes time and it is expensive. We have published recently that the efficacy and effectiveness of CPAP titration by autoCPAP devices (autoadjusted) or predicted by formula are similar to the conventional titration. Objective: To estimate the relation cost/efficacy in the three CPAP titration models. Method: 315 patients with SAHS, subsidiary of CPAP treatment (from 10 sleep centers), were included. They were distributed at random in conventional titration (107), autoadjusted (106) and predicted (102). In the last one the calculation allowed us to adjust the pressure between 7-9 cmH2O. Values higher than 9 were fixed according to the presence of snoring or apneas observed by the partner. The cost was calculated in two levels (high and low). Furthermore, additional expenses were considered in the autoCPAP reading and repeated studies in the autoadjusted titration and phone calls and domiciliary visits for pressure increases in the predicted titration. Costs were taxed depending on the percentage of rejected cases due to specific causes (i.e. no partner at home in the predicted model) and the percentage of patients who didn't reach any titration in each model. In this case, the cost of PSG was used. The efficacy variable was AHI. Results: The conventional titration had a significantly worse relation cost/efficacy than the other two models in any estimation (low or high) (P<0.0001). The autoadjusted titration was significantly better than the predicted one (P< 0.0001), except for the high estimation with PSG as an alternative for those cases impossible to titrate. Conclusions: Autoadjusted or predicted CPAP titrations are more advisable than the conventional one. Supported by: SEPAR and FIS

P2402 Nasal resistance and CPAP compliance in a large series of obstructive sleep apnea (OSA) patients Johan A. Verbraecken 1 , Frank Van Sprundel 1,2 , Tina Bal 1,2 , Evert Hamans 2 , An Boudewyns 2 , Paul H. Van de Heyning 2 , Wilfried A. De Backer 1 . 1 Dept of Pulmonary Medicine, University Hospital Antwerp, Edegem (Antwerp), Belgium; 2 Dept of ENT, University Hospital Antwerp, Edegem (Antwerp), Belgium Introduction: Nasal resistance (Rnas) has been found to be increased in patients with habitual snoring and OSA [Blakley et al,1987,97:752-754]. In a previous study we reported that an increased Rnas is associated with decreased CPAP compliance in OSA patients [ERJ 1995, 8, suppl 19, 325s]. The number of patients studied was however small (n=26) and the findings not yet statistically significant. Aim: to evaluate this relationship in an enlarged number of OSA patients. Rnas was measured with anterior rhinomanometry (RMM) (seated position; fixed pressure gradient of 150 Pa) before the start of CPAP therapy. Results: Rnas was normal or slightly increased (< 0.50 Pa/cm3 /s) in 110/145 patients (76%)[Group 1, AHI47 ± 30; BMI 31 ± 6, M/F 92/18] and severely increased (> 0.50 Pa/cm3 /s) in 35/145 patients (24%) [Group 2, AHI 47 ± 28,

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Thematic Poster Session

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BMI 29 ± 5, M/F 35/0]. No significant correlation was found between Rnas and subjective or objective CPAP compliance. There was even a significantly higher subjective CPAP use in Group 2, while no difference in objective use could be found. The number of patients interrupting their CPAP therapy was small in both groups (3.3% and 2,8% respectively).

Group 1 (n=110) Rnas (Pa/cm3/s) Nights per week Hours per night Reported % of sleep CPAP-counter (h/night) 0.27 ± 0.26 6.6 ± 1.1 6.7 ± 1.5 89 ± 17 6.2 ± 2.3 Group 2 (n=35) 1.19 ± 1.12 6.3 ± 1.4 5.9 ± 1.9 82 ± 27 6.3 ± 1.8 p <0.01 0.33 0.03 0.35 0.76

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P2405 Prevalence of ventilatory therapies in Alicante (Spain): evolution during 10 years Esther Pastor, Eusebi Chiner, Elia Gómez-Merino, Mónica Llombart, Cristina Senent, Ada Luz Andreu, Ana Camarasa, Jaime Signes-Costa, Juan Manuel Arriero, Juan Marco. Pneumology, H. Univ. Sant Joan d'Alacant, Alicante, Spain The prevalence of sleep breathing disorders (SBD) can be estimated by studying the level of prescription of ventilatory therapies (VT). We describe the evolution of VT prevalence per 100000 inhabitants (CPAP, bilevel (BL) or volumetric (V) ventilators) in Alicante Province from 1995 to 2005 and all VT prescribed by our Sleep Unit (SU) either to patients from our Health Area or to patients referred from other Health Areas. Data were collected by reviewing the reports of the providers. The total population in Alicante Province was 1461925 and 205000 in our Health Area (16 Area). There are 33-fold increase since 189 CPAP and 1 V prescribed in Alicante in 1995 (15/100000) to 6069 CPAP, 432 BL and 26 V (494/100000) prescribed in 2005. VT in our Area in 1995 were 120 CPAP, 2 BL and 1 V (85/100000), which increased to 630 CPAP, 178 BL and 21 V in 2005 (892/100000) (10.5-fold). VT prescribed by our SU to other Health Areas were 1005 CPAP, 49 BL and 1 V, a contribution of 44% to the total prevalence of the Alicante Province. We conclude that VT have shown a huge increment in Alicante Province, which implies an improvement in the diagnostic level and resources. The high rate of treatments prescribed from our SU to other Health Areas discloses an efficient coordination and resources management.

Conclusion: Objective long-term CPAP compliance is not influenced by an increased Rnas in OSA patients. This study does however not rule out an influence on CPAP compliance of Rnas changes in the supine position.

P2403 Does personality change in obstructive sleep apnea (OSA) patients using CPAP? Helen Michielsen 1 , Loes Verberne 1 , Danielle Mol 1 , Souad Bouhadan 2 , Rizvana Amir 2 , Anneke van Hoek 1 , Angelina der Kinderen 1 , Wilfried A. De Backer 2 , Johan A. Verbraecken 2 . 1 Dept of Psychology and Health, Medical Psychology, Tilburg University, Tilburg, The Netherlands; 2 Dept of Pulmonary Medicine, University Hospital Antwerp, Edegem (Antwerp), Belgium Introduction: Earlier studies indicated that OSA patients were somewhat more neurotic, more hypochondriacal and hysterical than normals. Treatment should therefore turn back the personality change. Personality factors like neuroticism are associated with a worse quality of life (QOL). Aim of this study was threefold: to examine whether personality of OSA patients differs from controls with similar complaints (fatigue/snoring), whether their personality changes after using CPAP for 4 months, and whether personality factors and QOL are associated in this patient group. Methods: 94 OSA patients (AHI=35) from the University Hospital Antwerp, Belgium, participated in this study. Additionally, a gender (77 males), age (51±9) and BMI (29.3±6.6) matched control group with nonapneic snoring or mild OSA (AHI=14) was obtained. The NEO-FFI personality scale and a disease specific QOL scale (SAQLI) were completed before diagnosis and after 4M CPAP, the patients completed the NEO-FFI again. Results: OSA patients and their controls did not differ on any of the personality factors. Personality did not change after 4M CPAP. At baseline, strong relationships were found between NEO-Extraversion and SAQLI Emotional Functioning (r=.52) and between NEO-Neuroticism and SAQLI Emotional Functioning (r=.66)/SAQLI Social Interaction (r=-.53, all ps<0.001), after controlling for AHI. Conclusion: Our preliminary results indicate that within this pilot group, no change in personality scores were found. Personality was associated with disease specific QOL. If replicated, these results demonstrate the need for specific psychological interventions for specific types of OSA patients.

P2406 Auto-titrating CPAP for treating obstructive sleep apnoea, a bimodal response in males? E. Mark Williams, B. Coker, A. Boal, V. Prathibha. William Harvey Hospital, Ashford, Kent, United Kingdom Obstructive sleep apnoea (OSA) is a widely recognized disorder and the mainstay of treatment is the application of continuous positive airway pressure (CPAP) during sleep. Auto-titrating CPAP devices can be used to estimate the optimum delivery pressure. This retrospective study assesses the link between the overnight mean pressure required for treatment, Pm, body mass index, BMI and the presenting apnoea-hypopnea index, AHI. Patients (n = 107, mean age 54 ± 12 yrs, M84: F23), with OSA (AHI > 10 events h-1 ), underwent the auto-titrating CPAP trial (REMstar Auto). The Pm delivered overnight was 8 ± 3 cm H2 O (Range 4 -16 cm H2 O). The mean BMI was 34 ± 7 kg M-2 , Epworth Score 14 ± 5 and AHI 33 ± 20 events h-1 . In females there was linear correlation (r2 = 0.46, p < 0.001) between Pm and AHI. In males two groups were discernable, in the largest group (n = 68), at a lower AHI (10-40 events h-1 ) there was a linear relationship, which then plateaued as AHI increased (r2 = 0. 48, p < 0.001). There were no correlations between Pm, BMI (34 ± 6 kg M-2 ), or Epworth Score (14 ± 5). In males a bimodal relationship is apparent when the AHI score was above 30. In a smaller group (n = 16), Pm was not correlated with AHI (r2 = 0.30, p = 0.50), with the optimum pressure remaining around 6 ± 1 cm H2 O across all AHI values. In females, there is a direct link between AHI and the level of pressure support needed. However, in males the distinction is less clear and although there is a link between AHI and Pm, it is only effective for some patients in the mid range between 10 and 40 events h-1 . This suggests that factors other than AHI are involved in determining the optimum pressure required to treat OSA.

P2404 AutoCPAP in obstructive sleep apnea (OSA) patients with poor compliance to standard CPAP titration Vincenza Castronovo, Maria Livia Fantini, Sara Marelli, Marco Zucconi, Luigi Ferini-Strambi. Sleep Disorders Center, University Vita-Salute San Raffaele, Milano, Italy Continuous positive airways pressure (CPAP) is considered the standard treatment for the management of OSA patients. CPAP titration is still considered the gold standard for determining the level of pressure required for each patient. However a proportion of patients remain untreated because of the lack of acceptance to this treatment. Several studies demonstrated that auto-titrating positive airways pressure (APAP) devices improve compliance, comfort and therefore adherence to treatment. Aim of the study was to evaluate acceptance and compliance to APAP in a population of OSA patients in which standard manual titration failed and therefore have been considered "untreatable". 376 consecutive severe OSA patients (AHI>=20) underwent one full-night PSG manual CPAP titration. Based on compliance (time spent with CPAP on), patients were classified as: compliant (C; >4 hours) and not compliant (NC) including those who were poorly compliant (NC1; between 2 and 4 hours) and those not compliant (NC0; less than 2 hours). 46 patients (12.2%) were classified as NC (NC0:n=32; NC1: n=14) and therefore were treated with APAP. Nine patients still had a compliance < than 4 hours while 34/46 (73.9%) patients showed a good compliance to APAP (mean average use: 6.7±1.5 hours).The vast majority of patients in which manual CPAP titration failed surprisingly showed good compliance to APAP. Our data suggest that APAP could be a valid therapeutic alternative in those patients judged "untreatable" with conventional respiratory devices before considering other treatment options (weight loss, ENT surgery etc.).

P2407 Impact of humidification on compliance and side effects in obstructive sleep apnea (OSA) patients under auto continuous positive airway pressure (ACPAP) therapy Sara Salgado 1 , Jose Boleo-Tome 1 , Rita Dias 1 , Cristina Canhao 1 , Joana Teixeira 1 , Amelia Feliciano 1 , Antonio Bugalho 2 , Odete Santos 1 , Paula Pinto 2 , Cristina Barbara 2 , Maria Joao Marques Gomes 2 . 1 Pneumologia, Hospital Pulido Valente, Lisbon, Portugal; 2 Centro de Estudos de Patologia Respiratoria, Faculdade de Ciencias Medicas, Lisbon, Portugal Objectives: To study the impact of heated humidification at the beginning of ACPAP therapy on compliance and side effects. Design: 39 patients with OSA naïve to CPAP therapy, were randomized to receive this treatment with (Group A) or without heated humidification (Group B). Patients were followed up at 1 week and 1 month. Outcome measures were ACPAP compliance (mean hours/night), side effects (dry nose/mouth, nasal congestion, runny nose), daytime sleepiness (Epworth Sleepiness Scale score) and subjective confort (visual analogic scale score). Patients were also evaluated for residual Apnea/Hypopnea Index (AHI), ACPAP mean pressures and leaks. Results: The two groups of patients studied were no different concerning mean age (Group A-57 / Group B- 57 years), AHI (Group A-28 / Group B- 29 events/hour), basal daytime sleepiness score (Group A-11 / Group B- 12) and nasal symptoms. Compliance at 1 month was similar in both groups (Group A- 5,3±2,3 / Group B 5,2±2,4 hours/night). There were also no differences in the other outcome measures. Conclusion: Our data indicates that there is no advantage in the addition of heated humidification at the beginning of ACPAP therapy. Supported by Feder/POCI/FCT/Centro de Estudos de Patologia Respiratoria.

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Thematic Poster Session

M ONDAY, S EPTEMBER 4 TH 2006

P2408 Effects of nCPAP treatment on quality of life of patients with obstructive sleep apnoea syndrome Domenico M. Toraldo 1 , Giuseppe Nicolardi 2 , Francesco De Nuccio 2 . 1 III Division, Pulmonary Hospital 'A. Galateo', San Cesario, LE, Italy; 2 Department of Biological and Environmental Technologies and Sciences, University of Lecce, Lecce, LE, Italy Aim of the study was to evaluate the effect of nocturnal Continuous Positive Airflow Pressure (nCPAP) treatment on day-time hypercapnia and Epworth Sleepiness Scale (ESS) score and nocturnal oximetry evaluation in patients with Obstructive Sleep Apnoea Syndrome (OSAS) without chronic obstructive pulmonary disease. 23 OSAS patients, 13 males and 10 females, were studied before and after three months of nCPAP/Bilevel home treatment, whose effects are summarized in table 1.

Table 1. Mean ± SD and Ranges of the Clinical Variables Studied in the 23 OSAS Patients Variable ESS PaCO2 PaO2 Pimax BMI MPAP FEV1 FEV1/FVC MSaO2 NSaO2 T90 ns = not significant month 0 19.56±2.38 47.81±3.13 75.29±2.46 49.39±5.35 35.03±3.50 27.04±3.49 95.84±2.74 85.59±5.28 86.80±2.69 72.67±5.11 36.00±5.51 month 3 7.43±1.92 38.55±3.74 78.58±2.98 62.65±4.76 33.46±2.92 20.39±2.01 97.21±2.07 88.82±4.73 91.08±0.91 82.77±2.67 23.20±3.93 difference % -62.01 -19.37 4.37 26.85 -4.48 -24.59 1.43 3.77 4.93 13.90 -35.56 P value 1.0 E-12 1.1E-11 0,00018 2.35E-11 0.10 (ns) 5.55E-10 0.06 (ns) 0.03 5.40E-9 1.05E-10 1.27E-11

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P2410 Comparative study of an auto-CPAP-titration device v.s. manual CPAP titration Juergen Herold, Andrea Steinmann, Elke Roessner, Joachim H. Ficker. 3rd Medical Department, Pneumology, Nuernberg, Germany Introduction Auto-titration devices are used for initiating pressure-constant CPAPtherapy in patients with OSA. We studied an auto-titration device controlled by FOT, flow and snoring (APAPFOT,Flow ; Somnoset® , Weinmann, Hamburg, Germany) vs. manual CPAP titration in the sleep lab. Methods We compared the PSG data and 2 week follow up data of 25 patients with OSA and automatic CPAP titration in two titration nights, to 25 patients with manual CPAP titration. Results The mean AHI and arousal index was reduced significantly from baseline PSG to first and second titration night in both groups. The mean AHI and arousal index of the first titration night was significantly lower in the group with automatic titration. There were no significant differences in mean AHI and arousal index in the respective second titration nights between the two groups. The recommended final CPAP pressures showed no significant difference between the two groups. There were also no significant differences between the two groups in sleep- and O2parameters. After two weeks of home therapy with the determined CPAP pressure both groups showed a significant decrease in ESS and a significant decrease of fatigue, and there were no significant differences in these parameters between the two groups. There were also no significant differences in time of usage per night, percentage of usage days and side effects between the two groups. Discussion In this study the APAPFOT,Flow demonstrated very reasonable pressure titrations. After two weeks with home CPAP therapy we found no differences in treatment quality or compliance. This study will be confirmed to determin whether these results can be confirmed in longterm use.

By hierarchical cluster analysis performed with T90, BMI and PaCO2 values, we recognized 5 groups of patients showed in table 2.

Table 2. Variable Centroid Values of 5 groups of patients (Clusters) identified by cluster analysis Cluster 1 2 3 4 5 T90 41.85 43.94 32.85 44.23 44.98 BMI 31.67 34.33 35.30 41.54 35.89 PaCO2 46.33 56.39 46.81 50.00 49.00 Patients 3 2 16 1 1 % 13.04 8.70 69.57 4.35 4.35

P2411 Evaluation of auto-CPAP algorithm using upper-airway simulated model Minoru Hirose 1 , Junich Honda 2 , Eiji Sato 1 , Toshihiro Shinbo 1 , Kenichi Kokubo 1 , Hirosuke Kobayashi 1 . 1 Department of Clinical Engineering, School of Allied Health Sciences, Kitasato University, Sagamihara, Kanagawa, Japan; 2 Department of Clinical Engineering, Fujinomiya City General Hospital, Fujinomiya, Shizuoka, Japan Objective The algorithm of commercially available automatic continuous positive airway pressure (auto-CPAP) devices for obstructive sleep apnea/hypopnea syndrome were compared and tested in order to verify the algorithm and characteristics of each auto-CPAP device. Methods We designed the upper-airway simulated model with spontaneous breathing and several respiratory events: apnea, hypopnea, flow-limitation and snore. Five auto-CPAP devices, AutoSetT® , AutoSetS® , Goodnight420E® , PV10i® and REMstar® were tested using this upper-airway model. Results Apnea: Although every device automatically increased the pressure level of auto-CPAP, AutoSetT® and AutoSetS® did not respond to apnea for 30 seconds, while other 3 devices increased the pressure level after apnea for 12 to 30 seconds; Hypopnea: All the devices except AutoSetS® and Goodnight420E® increased the pressure level. Flow-limitation: All the devices except PV10i® and REMstar® increased the pressure level.; Snore: The sound level of snoring was reduced on REMstar® and PV10i® , and Goodnight420E® have lowered the level of snoring. Conclusions The algorithm of commercially available auto-CPAP devices to the respiratory events differ in each company. Therefore, to verify each algorithm, carefully-controlled study under the same upper-airway condition is important, and the upper-airway simulated model, which we designed, is considered to be useful to test the algorithm. This study disclosed that the algorithm of auto-CPAP devices differed each other in response to apnea, hyponea, flow-limitation and snore.

In patients of group 3 only, PaCO2 correlated with BMI, suggesting a role of obesity in hypercapnia.

P2409 Age at diagnosis is not related to CPAP use over the first year when treating obstructive sleep apnoea Robin Ghosal 1 , Robert N. Sykes 1 , Keir E. Lewis 1,2 . 1 Respiratory Unit, Prince Philip Hospital, Llanelli, Wales, United Kingdom; 2 School of Medicine, University of Wales Swansea, Swansea, Wales, United Kingdom Introduction: Whether age correlates with CPAP use for OSA is controversial. Some report older people use CPAP less 1 , others report that older people use it more 2 . We hypothesized that both extremes of age are poor users i.e. that the relationship between age and use would be quadratic not linear. Methods: Prospective, single-blinded, observational study, with ethical approval. Patients: 72 consecutive patients (62 males) with daytime sleepiness and an AHI>10 events/ hour. They had mean (SD) age of 56.8 (8.7) years, BMI 36.4 (6.0) kg/m2, Epworth score 15.7 (4.3), AHI 42.5 (26.6) events/ hour. Procedure: All were CPAP naive and were advised to use their machines as much as possible when asleep but were not told that their machine use would be measured. Mean nightly use was estimated at 1, 6 and 12 months using hidden clock timers. All timer covers were sealed and were intact at each review. Statistics: Pearson's r assesed for linear correlations. The effect of age was examined in an ANOVA with age group (<50 years, 50-59 years, 60-69 years, >69 years) as the between-subjects factor and session (1,6, 12 months) as the within-subjects factor. Greenhouse-Geisser corrections were applied to the within subjects effects. Results: a) Pearsons r between age and CPAP use at 1 month r=0.13, p=0.33; 6 months r=0.01, p=0.96; 12 months r=-0.03, p=0.81. b) ANOVA showed no evidence of Age Group effect on use F(3,55)=0.81, p=0.91 and no evidence of Age Group by Session interaction F(5,92)=0.79,p=0.56. Conclusion: Age does not relate to CPAP use over the first year of treatment, either in a linear or non-linear fashion. References: 1. Resp Med 2000;94(1):76 2. Chest 2002;121(2):430

P2412 The clinical efficacy and comfort of modified automatic positive airway pressure (APAP) mode compared with continuous positive airway presure (CPAP) Rob Jarvis 1 , Alison Hansford 2 , Craig Little 1 , Jin Qian 1 , Peter Cistulli 1 . 1 Department of Respiratory & Sleep Medicine, St George Hospital, Kogarah, NSW, Australia; 2 Clinical & Research Services, ResMed Ltd, North Ryde, NSW, Australia Introduction: Modified APAP (modified AutoSetTM, ResMed Ltd) delivers bilevel pressure, with the pressure support level set for user comfort, and the mean pressure determined by a modified APAP algorithm. This may increase patient comfort but may also cause break through residual respiratory events. The aim of the study was to investigate the clinical efficacy and comfort and satisfaction of modified APAP mode compared to CPAP. Methods: Subjects diagnosed with obstructive sleep apnoea (OSA), established on CPAP therapy, were recruited to this randomized single blinded study. Subjects gave written informed consent. Subjects trialed the modified APAP, in modified APAP mode and CPAP mode, in a randomized order, for 2 weeks in each mode, in their own home. Subjects returned to the sleep center for each mode change and at that time: (1) had the modified APAP downloaded [Apnoea-Hypopnoea Index (AHI), Apnoea Index (AI), Hypopnoea Index (HI), Leak, Pressures and Usage data] (2) completed subjective questionnaires relating to comfort and satisfaction

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for that mode. These outcome measures were compared for modified APAP mode vs CPAP. Results: 20 subjects completed the study [18M:2F, mean age: 56yr (31-81), mean BMI: 34.6 kg/m2 (23-53.6)]. There was no difference between modified APAP and CPAP with respect to Average Usage, AHI, AI, HI, Maximum Pressure and Maximum Leak. The modified APAP and CPAP modes were equally favoured with respect to comfort and satisfaction. Conclusion: Modified APAP mode is equivalent to CPAP in the efficacy of treatment of OSA. Modified APAP and CPAP modes are favoured equally with respect to comfort and satisfaction.

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P2413 Accuracy of CPAP prescription by different predicted equations in OSAS Oreste Marrone, Adriana Salvaggio, Salvatore Romano, Giuseppe Insalaco. Italian National Research Council, Institute of Biomedicine and Molecular Immunology "A. Monroy", Palermo, Italy Usefulness of formulas to predict effective CPAP level for OSAS treatment is under debate. In this study, CPAP levels calculated according to four different formulas [Stradling JR et al, Respir Med (2004) 98:152-4; Hoheisel GB et al, Am J Respir Crit Care Med (1994) 149:A496; Sériès F et al, Am J Respir Crit Care Med (2000) 162:94-7; Hoffstein V et al, Am J Respir Crit Care Med (1994) 150:486-8] were compared to effective CPAP level titrated during polysomnography. CPAP titration was preformed in 136 OSAS subjects (22 F, age 54 ± 11 yrs, BMI 34.6 ± 6.1 kg/m2 , AHI 58 ± 22) by means of one APAP device (Autoset T, ResMed) applied during a polysomnographic study. As effective pressure was considered the 95th centile pressure level delivered by the APAP, corrected according to the analysis of polysomnographic signals. Correlations between calculated and effective pressures were always significant, but loose (r2 between 0.044 and 0.139). Differences 2 cmH2 O from effective pressure were found for 78% pressure values calculated by Stradling's formula, and for 19­46% values calculated by the other formulas. Differences between 95th centile pressures and calculated pressures were slightly higher (64% pressure levels by Stradling's formula, and 14­32% by the other ones, differing 2 cmH2 O from 95th centile pressures). Differences between effective pressure and pressure calculated by Stradling's formula ranged between -3.5 and +6.5 cmH2 O. Only values calculated by one of the tested predictive formulas approximated sufficiently to the real effective pressure in a high percentage of cases, but even by that formula effective pressure is not estimated with acceptable accuracy in 1 out of 5 cases.

Results: The studied group presented a median age of 55 years, a mean BMI of 33,15 and a median AHI of 52,3/h. The median % of CPAP days used was 96,5 and the median hours of use per night was 6,1. At the beginning of the study 43,1% patients presented frequently/always nocturia; 34,5% nocturnal sweating; 29,3% gasping phenomena; 47,6% morning headache; 27,6% sexual dysfunction and 15,5% heartburn. Six months after treatment only 17,2%; 8,6%; 1,7%; 3,4%; 15,5% and 1,7% complained of those symptoms, respectively.The median ESS was 12,7 at the beginning and 4 in the end. None of the studied symptoms were associated with age, BMI, weight loss, OSA severity, CPAP compliance or smoking habits. Changes in gasping phenomena were significantly related to CPAP pressure and changes in heartburn with weight loss. Conclusions: OSA patients report frequently symptoms beyond hypersomnia. CPAP therapy reduces the studied complaints in the majority of the patients.

P2416 Inspiratory flow limitation: comparison of an exspiratory pressure relief CPAP system versus conventional CPAP therapy Andreas Jerrentrup, Lukas Jerrentrup, Karl Kesper, Sebastian Canisius, Thomas Ploch, Claus Vogelmeier, Heinrich F. Becker. Dept of Respiratory Medicine and Sleep Unit, Philipps University Marburg, Marburg, Germany Compliance with nasal continuous positive airway pressure (CPAP) treatment may be reduced due to difficulties when exhaling against a positive pressure. A recently introduced CPAP system (C-Flex) therefore lowers the expiratory pressure proportional to the patient's airflow. To evaluate the theoretical concern that this might induce flow limitations during inspiration, we measured the occurrence of flow limitation during sleep. 24 subjects with (according to conventional polysomngraphic criteria) optimally treated obstructive sleep apnea (mean age 52.7 ± 8.5 years, mean cpap pressure 9.7 ± 1.7 cm H2 O) were studied with polysomnography including respiratory flow and oesophageal pressure measurement. Conventional CPAP and the three pressure relief settings of C-Flex were applied in a randomised order both during NREM and REM sleep. Inspiratory flow limitation was measured with inspiratory pressure:flow relationships and defined as a period of decreasing flow rate with negative pressure dependence. 46669 breaths were analysed in total. The mean percentage of flow limited breaths in NREM sleep was 19.2% in CPAP mode and 18.4% in C-Flex mode. In REM sleep we counted a mean percentage of 21.5% flow limited breaths in CPAP mode and 20.7% in C-Flex mode. Equivalence testing confirmed equivalence between the C-Flex and CPAP mode for both NREM and REM sleep. The results confirm that there is no increase in the number of flow limitations during C-Flex mode compared to CPAP. Surprisingly we detected a high percentage of flow limitations. This might be due to the manual titration based on the removal of snoring. Using this method some flow limitations might still persist.

P2414 Evaluation of CPAP therapy with pressure relief Georg Nilius, Ulrike Domanski, Karl-Heinz Ruehle. Pneumologie, Klinik Ambrock, Hagen, Germany A new CPAP device with expiratory pressure relief has been developed (SOMNOsoft ® )with the goal of reducing the side effects of CPAP therapy. Critics of this new technology say that the pressure reduction could result in an increase of flow limitations under CPAP. For that reason the new device observes the flow curve and does not reduce expiratory pressure during valid flow limitations. The present study investigates the question of whether patients could be safely and effectively treated with the new algorithm. Method: Conventional CPAP titration was carried out overnight on 13 patients, mean age 54,3: (SD ± 12,4) years, mean BMI: 32,1 (SD ± 4,5) kg/m2 , mean ESS 17,7 (±4,4) mean minimal SaO2 : 73,8 (± 15,4) %, with a first-time diagnosis of OSAS. On the following night the patients were treated with the CPAP device equipped with pressure relief. CPAP pressure was titrated according to our sleep laboratory's standards for both nights. Results: The mean AHI could be reduced from 46,6 (±30,3) to 3,9 during SOMNOsoft+ therapy. The mean sleep efficiency was improved from 80,8 (± 12,5) % to 91,5 (± 10,1) % and the mean minimal SaO2 was improved from 73,8 (± 15,4) % to 89,4 (± 4,1) %. In cases of respiratory disturbance, the machine did not reduce the expiratory pressure profile (in 97% of all episodes). Conclusion: OSAS patients can be effectively treated with the new CPAP device (WEINMANN SOMNOsoft ® ).

P2417 Automatic CPAP-titration based on forced oscillation technique, flow and snore signals in the obstructive sleep apnea syndrome Wolfgang Galetke, Kerstin Richter, Norbert Anduleit, Winfried Randerath. Clinic for Pneumology and Allergology; Center for Sleep Medicine and Respiratory Care, Bethanien Hospital, Solingen, Germany Background: Manual titration is regarded as a gold standard to determine optimal CPAP pressure for long-term treatment with a conventional CPAP device. This procedure is not standardised and time consuming. We compared automatic titration and manual titration in patients with obstructive sleep apnea syndrome (OSAS). Methods: After diagnostic polysomnography (PSG) 30 OSAS patients (8 female, 22 male; aged 52.1 ± 5.0 years; BMI 33.6 ± 2.1 kg/m2 ; AHI 34.1 ± 18.2 /h) were titrated manually and automatically in random order. After six weeks treatment with fixed CPAP determined in the last mode a control PSG was performed. For automatic titration a new device based on forced oscillation technique, flow and snore signals was used (Somnoset® , Weinmann, Germany). Results: After six weeks AHI in patients with manual titration was 6.8 ± 4.3 /h vs. 6.4 ± 5.1 /h in patients with automatic titration (p = n.s.).Mean treatment pressure in the first group was 9.0 ± 3.2 vs. 8.3 ± 2.9 cmH2 O in the second group (p = n.s.). Sleep analysis data and ESS scores were not different in the two groups. Conclusions: Automatic titration based on forced oscillation technique, flow and snore signals is as effective as conventional manual titration in patients with OSAS.

P2415 CPAP therapy impact in OSA related symptoms ­ a prospective study Marta Drummond, Joao C. Winck, Jose A. Marques. Pulmonology, Hospital Sao Joao, Oporto, Portugal Introduction: OSA has been reported to be associated with a wide variety of symptoms others than excessive daytime sleepiness. Objective: To access the subjective effects of CPAP therapy in OSA related symptoms. Materials and Methods: We studied 55 male patients with moderate to severe OSA, confirmed by domiciliary sleep study. The patients answered a validated questionnaire concerning nocturnal gasping phenomena, nocturnal sweating, sexual dysfunction, morning headache, nocturnal heartburn and nocturia together with the Epworth Sleepiness Scale (ESS) before treatment and 6 months after the therapy.

P2418 Treatment control in risk patients with obstructive sleep apnea syndrome Wolfgang Galetke, Vita Andreevska, Winfried Randerath. Clinic for Pneumology and Allergology; Center for Sleep Medicine and Respiratory Care, Bethanien Hospital, Solingen, Germany Background: Obstructive sleep apnea syndrome (OSAS) is associated with cognitive impairment and an increased risk of traffic accidents and cardiovascular disease, especially in risk group patients with low treatment adherence or comorbidity. In-hospital treatment control may identify problems with CPAP therapy and therefore increase long-term CPAP use. Methods: 256 patients with newly diagnosed OSAS were divided into a risk group

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(presumably low treatment adherence, severe comorbidity, risk occupation such as commercial vehicle driver) and into a no risk group. Patients in the risk group had a in-hospital treatment control after 1 - 3 months. Problems with therapy and treatment interventions were analysed. Results: 146 patients (57%) were regarded as risk group patients. In 100 of these patients an in-hospital treatment control was performed. Treatment interventions were necessary in 57 patients (57%). Treatment adherence was suboptimal in 31 patients (31%) without evident problems. Only 12 patients (12%) had no problems or interventions. Treatment interventions included optimizing CPAP pressure (21%), optimizing mask fitting (18%), switching CPAP mode into another mode (44%) and performing MSLT in risk occupations (17%). Conclusions: In patients with OSAS there is a high percentage of risk group patients with low treatment adherence and comorbidity. Treatment interventions are necessary in most of these patients after a short treatment period. For these patients an in-hospital treatment control is strongly recommended.

Hall B2-6 - 12:50-14:40

P2419 CPAP variability in long term follow-up of OSAS (obstructive sleep apnea syndrome) patients Levent Karasulu 1 , Atilla Uysal 1 , Levent Dalar 1 , Sedat Altin 1 , Pinar Ozkan 1 , Cuhadaroglu Caglar 2 . 1 Chest Medicine, Yedikule Chest Diseases and Chest Surgery Training Hospital, Istanbul, Turkey; 2 Chest Medicine, Faculty of Medicine University of Istanbul, Istanbul, Turkey Objective: In patients for whom positive air way pressure therapy is recommended, adjust pressure is found via pressure titration together with polysomnography. The purpose of our study is to determine the limits of long term pressure varibilities and to question the reliability of fixed pressure values obtained through titration in APAP users. Method: 58 patients using APAP were accepted into the study. 6 (9.5%) of patients were women and 57 (90.5%) of them men. Mean age was 50±12 (min: 24- max: 76), mean apne- hypopnea index was 37.17±14.04 (min: 12- max: 79). Upper and lower pressure limits were adjusted respectively as 6 and 15 mBar. Machine recordings were accepted as basis. Means and standart deviations for each case was calculated. This way a new series was obtained for a total of 11536 night recordings and another mean and standart deviation calculated. Result: 90% of nightly pressure variation for 11536 nights were between 2 standart deviations. Conclusion: Long term mean variability in pressure needs of the patients was 1.5 mBar. Minimum variability was 0.5 mBar. Maximum variability was 4.5 mBar. In only 10% of the patients pressure need was out of 2m Bar limits. Fluctiotions in pressure needs were narrowly limited and in the long term variabilities in daily life had no effect on them.

P2420 Effect of heated humidification and topical steroids on compliance, nasal symptoms and quality of life in patients with obstructive sleep apnoea syndrome using nasal continuous positive airway pressure Silke Ryan, Liam S. Doherty, Geraldine M. Nolan, Walter T. McNicholas. Sleep Disorders Unit, St. Vincent's University Hospital, Dublin, Ireland Introduction: Nasal side effects are common in patients with obstructive sleep apnoea syndrome (OSAS) starting on nasal continuous positive airway pressure (nCPAP) therapy. We tested the hypothesis that heated humidification or nasal topical steroids improve compliance, nasal side effects and quality of life in this patient group. Methods: 125 patients with the established diagnosis of OSAS (apnoea/hypopnoea index 15/hr), able and willing to tolerate nCPAP and who had a successful CPAP titration were randomised to 4 weeks of dry CPAP, humidified CPAP or CPAP with additional nasal steroids (Fluticasone, GlaxoSmithKline). Groups were similar in all demographic parameters and frequency of nasal symptoms at baseline. Outcome measures were objective compliance, quality of life (short form 36), subjective sleepiness (Epworth Sleepiness Score [ESS]) and nasal symptoms such as runny, dry or blocked nose, sneezing and headaches. Results: There was no difference in compliance between groups after 4 weeks of treatment. Quality of life and subjective sleepiness improved in all groups, but there was no difference in the extent of improvement. Nasal Symptoms were less frequent reported in the humidifier group (23%) than in the remaining groups (dry: 55%, p=0.008; steroids: 58%, p=0.002) but there was no difference between the dry CPAP and nasal steroid cohort. Conclusion: The addition of a humidifier, but not nasal steroids decreases the frequency of nasal symptoms in patients initiating nCPAP; however compliance remains unaltered.

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