Randomised controlled trial of polysomnographic titration of non-invasive ventilation.

Abstract

Non-invasive ventilation settings determined during wakefulness may produce patient-ventilator asynchrony during sleep, causing sleep disruption and limiting tolerance. This study investigated whether non-invasive ventilation titrated with polysomnography is associated with less patient-ventilator asynchrony and sleep disruption than therapy titrated during wakefulness alone.Treatment naïve individuals referred for non-invasive ventilation were randomised to Control (daytime titration followed by sham polysomnographic titration) or Polysomnography (daytime titration followed by polysomnographic titration) groups. Primary outcomes were patient-ventilator asynchrony and arousal indices on polysomnography at 10 weeks. Secondary outcomes included adherence, gas exchange, symptoms and health-related quality of life.Sixty participants were randomised. Most (88.3%) had a neuromuscular disorder and respiratory muscle weakness but minor derangements in daytime arterial blood gases. Patient-ventilator asynchrony events were less frequent in those undergoing polysomnographic titration ([median (interquartile range)]: Polysomnography 25.7/hr (12-68) versus Control 41.0/hr (28-182), p=0.046) but arousals were not significantly different ([median (interquartile range)]: Polysomnography 11.4/hr (9-19) versus Control 14.6/hr (11-19), p=0.258). Overall adherence was not different except in those with poor early adherence (<4 h·day-1) who increased their use after polysomnographic titration (mean difference (95% CI); Polysomnography +95 min·day-1 (29 to 161) versus Control -23 min·day-1 (-86 to 39), p=0.01). PaCO2, somnolence and sleep quality improved in both groups. There were no differences in nocturnal gas exchange or overall measures of health-related quality of life.Non-invasive ventilation titrated with polysomnography is associated with less patient-ventilator asynchrony but not less sleep disruption when compared to therapy titrated during daytime alone.