Sleep disorders and exercise: a mini-review.

Sleep disturbance in a growing problem in the general population. As the prevalence of sleep disturbance rises, interest in treatment modalities including non-pharmaceutical interventions also grows. One of these potential modalities is exercise therapy. In individuals without sleep disorders, exercise appears to be beneficial in improving sleep architecture without any impact of the timing of exercise in relation to onset of sleep. The mechanisms for this are largely unknown but may be due to a combination of the effects of exercise on body temperature, autonomic control, endocrine and metabolic function. In obstructive sleep apnoea (OSA), supervised exercise therapy appears to have positive impact on daytime sleepiness with an unknown impact on sleep quality. The effect of exercise on central sleep apnoea (CSA) will be difficult to ascertain due to the low prevalence of this condition. In primary sleep disorders such as insomnia, narcolepsy and restless syndrome exercise may be useful in improving sleep architecture but the quality of the evidence supporting this remains low. In addition, the timing of exercise in relation to sleep onset remains under investigated. In individuals with circadian rhythm disorders, evening exercise appears to delay sleep onset. In shift-pattern workers, individuals with increased cardiorespiratory fitness report better sleep quality, suggesting exercise may be protective in this important population. To allow high quality evidence-based recommendations to be made about the value of exercise in individuals with sleep disorders, there is a significant need for large prospective studies with objective and subjective sleep quality as a primary outcome.

Home parasternal electromyography tracks patient-reported and physiological measures of recovery from severe COPD exacerbation.

Physiological phenotyping using daily home-based assessments reveals early improvement in load-capacity-drive imbalance following #AECOPD and feasibility of home parasternal electromyography measurement, which tracks symptoms, health status and spirometry https://bit.ly/3o6I0Ty.

Novel modes of non-invasive ventilation in chronic respiratory failure: a narrative review.

Home non-invasive ventilation (NIV) is central in the management of chronic hypercapnic respiratory failure and is associated with improvements in clinically relevant outcomes. Home NIV typically involves delivery of fixed positive inspiratory and expiratory airway pressures. These pressures do not reflect physiological changes to respiratory mechanics and airway calibre during sleep, which may impact on physiological efficacy, subsequent clinical outcomes, and therapy adherence. Novel ventilator modes have been designed in an attempt to address these issues. Volume-assured pressure support modes aim to automatically adjust inspiratory pressure to achieve a pre-set target tidal volume. The addition of auto-titrating expiratory pressure to maintain upper airway calibre is designed for patients at risk of upper airway collapse, such as obese patients and those with obstructive sleep apnoea complicating their hypercapnic failure. Heterogeneity in setup protocols, patient selection and trial design limit firm conclusions to be drawn on the clinical efficacy of these modes. However, there are data to suggest that compared to fixed-pressure NIV, volume-assured modes may improve nocturnal carbon dioxide, sleep quality and ventilator adherence in select patients. The use of the forced oscillation technique to identify expiratory flow limitation and adjust expiratory pressure to eliminate it is the most recent addition to these advanced modes and is yet to be assessed in formal clinical trials.

Respiratory failure and sleep-disordered breathing in late-onset Pompe disease: a narrative review.

Late-onset Pompe disease (LOPD) is a rare autosomal recessive glycogen storage disease that results in accumulation of glycogen in muscle cells causing muscular weakness. It causes a progressive proximal myopathy, accompanied by respiratory muscle weakness, which can lead to ventilatory failure. In untreated LOPD, the most common cause of death is respiratory failure. Patients suffering from respiratory compromise may present with symptoms of sleep-disordered breathing (SDB) before overt signs of respiratory failure. Diaphragm weakness leads to nocturnal hypoventilation, which can result in sleep disruption. Both subjective and objective sleep quality can be impaired with associated excessive daytime sleepiness (EDS). Health-related quality of life worsens as sleep disturbance increases. The mainstay of treatment for SDB and respiratory failure in LOPD is non-invasive ventilation (NIV), which aims to ensure adequate ventilation, particularly during sleep, and prevent acute hypercapnic failure. These patients are at risk of acute deterioration due to lower respiratory tract infections; effective secretion clearance and vaccination against common pathogens is an important facet of care. Whilst disease-modifying enzyme replacement therapy (ERT) delays progression of locomotor dysfunction and prolongs life, its effect on respiratory function and SDB remains unclear. There are no data demonstrating the impact of ERT on sleep quality or SDB.

Sleep disorder in patients with chronic liver disease: a narrative review.

Sleep disturbance is a common feature of chronic liver disease (CLD) with impact on health-related quality of life; 60-80% of patients with CLD report subjective poor sleep; frequent presentations of sleep disturbance include insomnia, reduced sleep efficiency, increased sleep latency, reduced time in rapid eye movement (REM) sleep, restless leg syndrome and excessive daytime sleepiness (EDS). Key contributors to sleep disturbance include hepatic encephalopathy (HE) and circadian rhythm imbalance due to altered melatonin metabolism. Specific conditions causing CLD, such as non-alcoholic fatty liver disease (NAFLD), chronic viral hepatitis and primary biliary cholangitis (PBC) result in different types of sleep disturbance, and the treatment of these conditions can often also lead to sleep disturbance. There are currently limited management options for sleep disturbance in CLD. Obstructive sleep apnoea (OSA) is a common condition that causes chronic intermittent hypoxia due to airway collapse during sleep. This chronic intermittent hypoxia appears to contribute to the development of NAFLD. The presence of reactive oxygen species and the overexpression of hypoxia inducible factor 1-alpha secondary to hypoxia may be responsible for the second 'hit' of the 'two-hit' hypothesis of NAFLD. Treatment of the intermittent hypoxia with continuous positive airway pressure therapy has limited efficacy against liver dysfunction. There remain many outstanding areas of investigation in the management of sleep disturbance in CLD, and of liver dysfunction in OSA.

Update: non-invasive ventilation in chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) remains a common cause of morbidity and mortality worldwide. Patients with COPD and respiratory failure, whether acute or chronic have a poorer prognosis than patients without respiratory failure. Non-invasive ventilation (NIV) has been shown to be a useful tool in both the acute hospital and chronic home care setting. NIV has been well established as the gold standard therapy for acute decompensated respiratory failure complicating an acute exacerbation of COPD with reduced mortality and intubation rates compared to standard therapy. However, NIV has been increasingly used in other clinical situations such as for weaning from invasive ventilation and to palliate symptoms in patients not suitable for invasive ventilation. The equivocal evidence for the use of NIV in chronic hypercapnic respiratory failure complicating COPD has recently been challenged with data now supporting a role for therapy in selected subgroups of patients. Finally the review will discuss the emerging role of high flow humidified therapy to support or replace NIV in certain clinical situation.