Usefulness of transcutaneous PCO 2 to assess nocturnal hypoventilation in restrictive lung disorders

Abstract : Background and objectiveNocturnal hypoventilation is now an accepted indication for the initiation of non-invasive ventilation. Nocturnal hypoventilation may be an under diagnosed condition in chronic respiratory failure. The most appropriate strategy to identify sleep hypoventilation is not yet clearly defined. In clinical practice, it is indirectly assessed using nocturnal pulse oximetry (NPO) and morning arterial blood gases (mABG). Even though continuous transcutaneous carbon dioxide partial pressure (TcPCO2) monitoring is theoretically superior to NPO plus mABG, it is not routinely used. We aimed to prospectively compare NPO plus mABG with nocturnal TcPCO2 for the detection of alveolar hypoventilation in a cohort of patients with chronic restrictive respiratory dysfunction. MethodsWe assessed 80 recordings of mABG, nocturnal TcPCO2 and NPO in 72 consecutive patients with neuromuscular disease or thoracic cage disorders. Nocturnal hypoventilation was defined as a mean nightime TcPCO2 50mmHg, and nocturnal hypoxaemia as 30% of the night with transcutaneous pulse oxygen saturation 90% and/or >5 consecutive minutes with transcutaneous pulse oxygen saturation 88%. ResultsAmongst the 80 recordings, 25 of 76 (32.9%) without nocturnal hypoxaemia and 16 of 59 (27.1%) without hypercapnia on mABG showed nocturnal hypoventilation on TcPCO2. Amongst recordings showing both normal NPO and mABG, 16 of 52 (30.8%) had a mean TcPCO2 50mmHg. Nocturnal hypoxaemia was associated with nocturnal hypoventilation in all recordings. However, 5 of 21 (23.8%) recordings that showed an absence of nocturnal hypoventilation at the chosen threshold showed hypercapnia on mABG. ConclusionMorning arterial blood gases and NPO alone or in combination underestimate nocturnal hypoventilation in patients with chronic restrictive respiratory dysfunction of extrapulmonary origin. This study demonstrates that compared with nocturnal transcutaneous PCO2, the combination of morning arterial blood gases and nocturnal pulse oxymetry underestimates the occurrence of nocturnal hypoventilation in one third of patients with neuromuscular and thoracic cage disorders at risk of respiratory failure