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• W2973164089 abstract "Free AccessLetters to the EditorAutocycling During Noninvasive Positive Pressure Ventilation Producing a Prolonged Severe Apnea and Syncope, Further Insights Susana Mu, MBBS Hons, Mark E. Howard, MBBS, FRACP, GDEB, PhD, Liam Hannan, MBBS, FRACP, PhD Susana Mu, MBBS Hons Austin Health, Heidelberg, Victoria, Australia Northern Health, Epping, Victoria, Australia Search for more papers by this author , Mark E. Howard, MBBS, FRACP, GDEB, PhD Austin Health, Heidelberg, Victoria, Australia Institute of Breathing and Sleep, Heidelberg, Victoria, Australia Victorian Respiratory Support Service, Heidelberg, Victoria, Australia University of Melbourne, Parkville, Victoria, Australia Search for more papers by this author , Liam Hannan, MBBS, FRACP, PhD Austin Health, Heidelberg, Victoria, Australia Northern Health, Epping, Victoria, Australia Institute of Breathing and Sleep, Heidelberg, Victoria, Australia Victorian Respiratory Support Service, Heidelberg, Victoria, Australia Search for more papers by this author Published Online:September 15, 2019https://doi.org/10.5664/jcsm.7950SectionsAbstractPDF ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations AboutCITATIONCITATIONMu S, Howard ME, Hannan L. Autocycling during noninvasive positive pressure ventilation producing a prolonged severe apnea and syncope, further insights. J Clin Sleep Med. 2019;15(9):1379.INTRODUCTIONWe thank Dr Karim and Professor Esquinas for their interest in our case report and we acknowledge that the alternative hypotheses they have proposed have face validity.1 It is certainly suspected clinically, although not confirmed objectively, that the patient described in this report has pulmonary hypertension and it is possible that this contributed to the prolongation of the oxygen desaturation observed during this event.2 We also agree that both response times and, potentially, accuracy (with reference to SaO2) may be better with ear probe pulse oximetry than finger probe. We believe that both the oximetry trace and transcutaneous carbon dioxide trace in combination with the reduction in spontaneous respiratory effort observed during the episode support our conclusion of a prolonged central apnea with associated hypoxaemia being the primary cause of syncope rather than this episode being explained by peripheral vasoconstriction in response to reduced cardiac output. In addition, the sequence of events that occurred on the night would also not support the alternative hypothesis. While we acknowledge that excessive ventilation from autocycling could have increased intrathoracic pressure thus compromising venous return and cardiac output,3,4 syncope occurred only on removal of ventilation rather than while it was applied, making it unlikely that this was the primary cause of syncope although it may have been a contributor to impaired oxygen delivery. This in combination with spontaneous improvement postevent and lack of postevent confusion or disorientation make the likelihood of primary cardiac or neurological explanations for this episode less likely.DISCLOSURE STATEMENTAll authors listed have seen and approved the manuscript. The authors report no conflicts of interest.REFERENCES1 Mu S, Rautela L, Howard ME, Hannan LAutocycling during noninvasive positive pressure ventilation producing a prolonged severe apnea and syncopeJ Clin Sleep Med20191504663665 LinkGoogle Scholar2 Inagaki T, Terada J, Yahaba M, et al.Heart rate and oxygen saturation change patterns during 6-min walk test in subject with chronic thromboembolic pulmonary hypertensionRespir Care2018635573583 CrossrefGoogle Scholar3 Jardin F, Farcot JC, Boisante L, Curien N, Margairaz A, Bourdarias JPInfluence of positive end-expiratory pressure on left ventricular performanceN Engl J Med19813047387392 CrossrefGoogle Scholar4 Gay PCComplications of non-invasive ventilation in acute careRespir Care2009542246257 Google Scholar Previous article Next article FiguresReferencesRelatedDetails Volume 15 • Issue 09 • September 15, 2019ISSN (print): 1550-9389ISSN (online): 1550-9397Frequency: Monthly Metrics History Submitted for publicationJuly 17, 2019Submitted in final revised formJuly 17, 2019Accepted for publicationJuly 17, 2019Published onlineSeptember 15, 2019 Information© 2019 American Academy of Sleep MedicinePDF download" @default.
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