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7431205 
Journal Article 
Nocturnal Noninvasive Ventilation and Adjuncts in Disorders of Breathing Control 
Thomas, RJ; , 
2015 
Springer US 
Boston, MA 
Nocturnal Non-Invasive Ventilation 
163-208 
Treatment of sleep apnea characterized by high respiratory control chemosensitivity is challenging. The key polysomnographic characteristics are non-rapid eye movement (NREM) dominance of respiratory events that exhibit a self-similar metronomic timing and spontaneous improvement during rapid eye movement (REM) sleep. As both sleep fragmentation and a narrow CO2 reserve or increased loop gain drive the disease, sedatives (to induce longer periods of stable NREM sleep and reduce the destabilizing effects of arousals in NREM sleep) and CO2-based stabilization approaches are logical. Adaptive ventilation reduces mean hyperventilation and can effectively treat central/complex apnea in a subset of patients, but can also induce ventilator-patient desynchrony. Enhanced expiratory rebreathing space (EERS, dead space during positive pressure therapy) directly stabilizes respiratory control by moving CO2 above the apnea threshold. Carbonic anhydrase inhibition can provide further adjunctive benefits. Provent, Winx, body positioning, and oral appliances can be part of effective multimodality therapy in individual patients.