Evaluation of an OSA risk stratifying and treatment protocol during inpatient rehabilitation of post-stroke patients

Abstract

Purpose

To evaluate outcomes, outside of a clinical trial setting, of a protocol utilizing overnight oximetry (NOx) to risk stratify post-stroke patients for obstructive sleep apnea (OSA) followed by autoadjusting continuous positive airway pressure (APAP) treatment in patients considered high risk for OSA.

Methods

Retrospective observational study of post-stroke patients at an academic inpatient stroke rehabilitation facility. Patients underwent NOx, and those at high risk for OSA (oxygen desaturation index 3% > 10 per hour) were attempted on a trial of APAP, and further stratified into high risk adherent with treatment (HRAT) or high-risk failed treatment (HRFT). Change in functional independence measure (FIM) was used to assess recovery.

Results

Two hundred twenty-four post-stroke patients underwent NOx, with 120 (53%) considered high risk for OSA. Twelve (10%) were compliant with APAP treatment (> 4 h/night on > 70% of nights). No difference in change in FIM scores was observed for HRAT versus HRFT [total FIM change − 5.8, 95% CI (− 13.9, 2.2); motor FIM change − 4.5, 95% CI (− 11.5, 2.4); cognitive FIM change − 1.3, 95% CI (−3.8, 1.2)]. A subgroup analysis matched 14 HRAT patients (using adherence criterion of APAP usage > 50% of nights) to 35 HRFT patients. A statistically significant, but clinically irrelevant, difference in total FIM change was observed (HRAT vs HRFT, difference between means − 5.2, p = 0.03).

Conclusions

The use of APAP in high-risk patients was poorly tolerated and did not improve post-stroke recovery. Further studies with larger sample sizes are needed to determine the effect of APAP treatment on short-term recovery.

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Abbreviations

ACPAP:

autoadjusting continuous positive airway pressure

AHI:

apnea-hypopnea index

BMI:

body mass index

CAD:

coronary artery disease

CHF:

congestive heart failure

COPD:

chronic obstructive pulmonary disease

CPAP:

continuous positive airway pressure

CSA:

central sleep apnea

CVA:

cerebrovascular accident

DBM:

difference between means

DM:

diabetes mellitus

FIM:

functional independence measure

HFpEF:

heart failure with preserved ejection fraction

HFrEF:

heart failure with reduced ejection fraction

HRAT:

high risk adherent with treatment

HRFT:

high risk failed treatment

HTN:

hypertension

IRF:

inpatient rehabilitation facility

LR:

low risk

NOx:

nocturnal oximetry

ODI3%:

oxygen desaturation index 3%

OSA:

obstructive sleep apnea

PAP:

positive airway pressure

PSG:

polysomnography

REI:

respiratory event index

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Correspondence to Dennis H. Auckley.

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Conflict of interest

Mr. McKee declares that he has no conflict of interest. Dr. Wilson declares that he has no conflict of interest. Dr. Auckley has received research grants from Medtronics.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent was waived by the IRB giving the retrospective nature of this study of current clinical practice at our institution. All data was de-identified.

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McKee, Z., Wilson, R.D. & Auckley, D.H. Evaluation of an OSA risk stratifying and treatment protocol during inpatient rehabilitation of post-stroke patients. Sleep Breath 24, 513–521 (2020). https://doi.org/10.1007/s11325-019-01887-3

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Keywords

  • Post-stroke obstructive sleep apnea
  • Obstructive sleep apnea
  • Stroke
  • Overnight oximetry
  • Autoadjusting continuous positive airway pressure
  • Functional independence measure