Effect of APAP and heated humidification with a heated breathing tube on adherence, quality of life, and nasopharyngealcomplaints A. Ozsancak Ugurlu & A. M. Esquinas
Sleep and Breathing International Journal of the Science and Practice of Sleep Medicine ISSN 1520-9512 Sleep Breath DOI 10.1007/s11325-015-1246-3
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Author's personal copy Sleep Breath DOI 10.1007/s11325-015-1246-3
SLEEP BREATHING PHYSIOLOGY AND DISORDERS • LETTER TO THE EDITORS
Effect of APAP and heated humidification with a heated breathing tube on adherence, quality of life, and nasopharyngeal complaints A. Ozsancak Ugurlu 1 & A. M. Esquinas 2
Received: 22 July 2015 / Accepted: 12 August 2015 # Springer-Verlag Berlin Heidelberg 2015
To the editor, Although humidifiers have been shown to demonstrate beneficial therapeutic effects during noninvasive ventilation use, there is still controversy whether humidification has any additional compliance benefit or not [1]. We read with great interest the article written by Nilius et al. [2] entitled ‘Effect of APAP and heated humidification with a heated breathing tube on adherence, quality of life, and nasopharyngeal complaints’ published online at May 10th, 2015. The study demonstrated that the additional use of heated humidifier (HH) with CPAP devices in obstructive sleep apnea patients with nasopharyngeal complaints (NPC) (such as dry nose, nasal congestion, or dry throat) leads to a tendency to improve CPAP adherence; however, it was not statistically significant. The HH was also shown to reduce NPC and sleepiness and to improve quality of life in the same patient population. The recent guideline by American Association of Respiratory Care published in 2012 [3] suggested the use of humidification for NIV with possibility of improvement in adherence and comfort. Additionally, the American Academy of Sleep Medicine initiated the use of humidification even from the start of a titration sleep study, if the patient complains of significant nasal or oral congestion, again relying on a possibility of its usefulness in selected group of patients with NPC or during selected climates (i.e., dry or cold) (4). Therefore,
* A. Ozsancak Ugurlu
[email protected] A. M. Esquinas
[email protected] 1
Department of Pulmonary Medicine, Baskent University Hospital, Istanbul, Turkey
2
Intensive Care and Non Invasive Ventilatory Unit, Hospital Morales Meseguer, Murcia, Spain
this study definitely requires attention, since it is one the few studies in this field. However, we have some concerns regarding to the methods and results. First, patients with apnea–hypopnea index more than 10 per hour were enrolled, including mild OSAS. Did patients with mild OSAS all have sleep symptoms or comorbidities such as hypertension? Second, the dropout rate in patients using HH was higher than control patients, especially in the high-risk group; can it be due to higher discomfort or patient dissatisfaction with HH? Although authors showed some tendency to improve adherence, it was not significant. However, Massie et al. was able to show significant increase in adherence in their 3-week cross-over study [5]. Nilius et al. proposed that the higher use by Massie could be related to a relatively high proportion of subjects with nasal problems; however, the high-risk group in Nilius’ study consists of patients with NPC, so all of them had nasal or pharyngeal symptoms. We think that Massie was able to show the difference due to their method of the study. If Nilius et al. had also performed this study in cross-over design, we think that they would most probably able to show the useful effect of HH on adherence. They provided the baseline characteristics of the subjects in Table 1, but they have not compared them. It seems that the patients on HH in each group had higher apnea hypopnea index, which might lead to higher levels of CPAP use, with a possibility of decrease in adherence. In the high-risk group, humidification resulted in decrease of NPC as shown in previous studies [1]. But it can be more important to underline that it also reduced sleepiness and quality of life accordingly. Patient satisfaction of the treatment could also be asked, since sometimes it can be uncomfortable for patients as well.
Author's personal copy Sleep Breath
Despite of its inability to show significant effect on compliance, this study provides many practical important data, such as global scoring of NPC. A larger study with blinded cross-over design may be a more promising research.
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References 1.
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Esquinas AM, Scala R, Soroksky A et al (2012) Clinical review: humidifiers during non-invasive ventilation- key topics and practical implications. Crit Care 16:203–209 Nilius G, Franke KJ, Domanski U, Schroeder M, Ruhle KH (2015) Effect of APAP and heated humidification with a heated breathing
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tube on adherence, quality of life, and nasopharyngeal complaints. Sleep Breath. [Epub ahead of print] Restrepo RD, Walsh BK (2012) AARC practice guideline. Humidification during invasive and noninvasive mechanical ventilation: 2012. Respir Care 57(5):782–788 Berry RB, Chediak A, Brown LK, NPPV Titration Task Force of the American Academy of Sleep Medicine et al (2010) Best clinical practices for the sleep center adjustment of noninvasive positive pressure ventilation (NPPV) in stable chronic alveolar hypoventilation syndromes. J Clin Sleep Med 6(5): 491–509 Massie CA, Hart RW, Peralez K, Richards GN (1999) Effects of humidification on nasal symptoms and compliance in sleep apnea patients using continuous positive airway pressure. Chest 116(2): 403–408
