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Title: Complex Sleep Apnea: And Other Treatment Challenges In Airway Pressure Therapy


1
Complex Sleep ApneaAnd OtherTreatment
ChallengesIn Airway Pressure Therapy
  • Brian J. Bohner, M.D.
  • Diplomate ABSM
  • Fellow AASM
  • Conference By The Sea
  • September 17, 2009

2
Complex Sleep ApneaAnd Other Treatment
Challenges In Airway Pressure Therapy Objectives
  • Complex Sleep Apnea Definition and Treatment
    Approaches
  • Five Key Challenges in nCPAP Compliance
  • 2009 CPAP Mask Awards

3
Case Study T.Y.
  • 54 Y.O. Male C/O
  • Daytime Sleepiness/Fatigue
  • 5-10 Awakenings per Night
  • Snoring
  • PMH
  • HTN
  • Lumbar Arthritis
  • No history or symptoms of CHF
  • Medications
  • Celebrex
  • Metoprolol
  • HCTZ
  • ROS
  • Nocturnal Reflux
  • Exam

4
Baseline Polysomnogram
5
Polysomnogram Results
  • Apnea Index 21.3
  • Apnea Hypopnea Index 43.1
  • Total Sleep Time 4.8 Hours
  • O2 Saturation Nadir 84
  • Trial of Automatic CPAP
  • Night to Night Variance in Selected Pressure
  • 6 to 15 cms H2O

6
CPAP Titration Study
7
CPAP Titration Development of Central Events
8
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9
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10
Classifications of Sleep Disordered Breathing
(SDB)
CSA/CSR lt 5
  • Paradoxical Response to CPAP
  • Development of Central Apnea
  • 2. Position Dependent SDBs
  • 3. Sleep Stage Dependent SDBs
  • 4. Time of Night Dependent SDBs
  • 5. Mixed Apneas

Undefined SDB 15
OSA 85
11
Complex Sleep ApneaDefinition
  • Complex Sleep Apnea is a form of sleep apnea in
    which central apneas persist or emerge during
    attempts to treat obstructive events with nCPAP.

12
Patient Characteristics
  • 1. gt 90 are Male (Ref 1, 2, 3)
  • 2. BMI is slightly less than average OSA
  • patient (Ref 2)
  • 3. Higher incidence of Atrial Fibrillation and
  • Opioid Use (Ref 4)
  • 4. Prevalence of 5-15 in OSA Patients (Ref 1,2)

References 1. Lehman Journal of Clinical Sleep
Medicine August 2007, p 462 466. 2.
Morgenhaler Sleep September 2006, p 1203
1209. 3. Thomas Sleep December 2007, p 1756
1769. 4. Javaheri JCSM 2009, Volume 5
13
Polysomnographic Characteristics
  • May have Evidence of Central Events on
  • Baseline PSG (Ref 2)
  • Events More Common in nREM sleep (Ref 3)
  • Elevated Arousal Index (Ref 3)
  • Decreased Central Events on Follow-up (Ref 1, 4)

References 1. Dernaika Chest July 2007, p
81-87 2. Lehman Journal of Clinical Sleep
Medicine August 2007, p 462 466. 3.
Morgenhaler Sleep September 2006, p 1203
1209. 4. Javaheri JCSM 2009, Volume 5
14
Clinical Impact of nCPAP in Complex Apnea
  • Residual or Worsening Symptoms
  • (Fatigue, EDS, Depression) Secondary to
    Arousals/Disrupted Sleep
  • 2. Higher Incidence of CPAP Difficulty (Ref 1)
  • 3. ? Sympathetic Activity (Ref 2)
  • References
  • Pusalavidyasagar Sleep Medicine September
    2006, p 474-479
  • Yumino Proc American Thoracic Society February
    2008, 226-236

15
Understanding Pathophysiology Of Complex Sleep
Apnea
16
Controls of Breathing AWAKE
xxx
  • Behavioral
  • Metabolic
  • Chemoreceptors
  • Carotid Bodies
  • Medulla

oo
oo
ooo
44
Eupnea
Y axis pCO2
CO2 Reserve
36
Apnea Threshold
17
Controls of Breathing - SLEEP
job
  • Loss of Behavioral Control
  • Narrow CO2 Reserve in nREM
  • Hypoxia Further Reduces pCO2
  • Metabolic Acidosis Widens CO2 Reserve

oo
Oo
REM
CO2 Reserve
nREM
Y axis pCO2
CO2 Reserve
39
Apnea Threshold
38
Apnea Threshold
18
Controls of Breathing During Sleep - CHF
ooo
ooo
1. Pulmonary Afferent Receptors
xxx xxx xxx
2. Loop Gain A. Increased Response to pCO2
o o
B. Increased Lung to Peripheral
Chemoreceptor Circulation Time
pCO2
Apnea Threshold
19
Controls of Breathing During SleepEffects of
nCPAP/Bilevel PAP
  • Effect of Opening Airway
  • ? Minute Ventilation
  • (Worse with Bi-Level)
  • 2. Fragmented Sleep with Arousal
  • ? pCO2.
  • 3. Impact of High Loop Gain

pCO2
CO2 Reserve
Apnea Threshold
20
Treatment Considerations in Complex Apnea
  • 1. Increase CO2 Reserve Value
  • ? O2
  • ? Induce Acidemia
  • Increase Dead Space
  • 2. Reduce Loop Gain
  • Treat CHF
  • ? Sedatives
  • 3. Provide Back-Up
  • Backup Rate on Therapy

21
Treatment Options
  • nCPAP with Permissive Flow Limitation
  • 2. nCPAP Disregarding Central Events
  • Supplemental O2
  • 4. Medications
  • Acetazolamide
  • Theophylline
  • Benzodiazepines
  • 5. Additional Dead Space to nCPAP
  • 6. Adaptive Servo Ventilation (ASV)

22
Adaptive Servo Ventilation (ASV)
  • Airway Pressure Device devised for Treatment of
    CSA/CSR as well as Complex Apnea
  • Automatic Pressure Support (Dynamically
  • Calculated) to result in Consistent Tidal
  • Volume
  • Automatic Backup Rate (Calculated)
  • Multiple Studies show Effective Clinical
  • Results in Treating Complex Apnea

23
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24
Respironics
  • BiPAP Auto SV
  • Responds to Peak Flow and Adjusts
  • Pressure Support Accordingly
  • Manufacturers Suggestion for Settings
  • Set EPAP per Titration Study (Pressure
    Eliminating Last
  • Obstructive Event)
  • Set IPAP min EPAP
  • Set IPAP max EPAP 10 cm (25-30 cms)
  • Set Rate Auto

25
Res Med
  • VPAP Adapt SV
  • Algorithm Directed at Measuring Baseline
  • TV and Respiratory Rate
  • Can Titrate for EPAP (EEP) or use Default
  • Setting of 5 cm
  • IPAP Suggestions
  • Set Min PS 3 cm
  • Set Max PS 15 cm

26
Patient T.Y. On ASV
27
Therapy for Complex Sleep ApneaConclusions
  • Adaptive Servo Ventilation (ASV)
  • Nasal CPAP With Careful Follow-Up
  • Possible Role for Modalities such as
  • A. O2 with nCPAP
  • B. Sedative Trial
  • C. Rebreathing Mask/Dead Space

28
Implications
  • To OSA Patient
  • 5-10 will not appropriately respond to nCPAP
  • Cost of Alternative Therapies may be Prohibitive
  • To Sleep Centers
  • Responsibility to Identify such patients and
    offer Treatment Modifications
  • To Sleep Medicine Society
  • Consider Consequences in Offering Home Studies
  • (Non-Titrated) as well as Automated CPAP

29
Challenges In nCPAP Compliance
30
Nasal CPAP Problem 1
  • Interface Intolerance/Discomfort/Mask Removal
  • ? Refitting
  • ? Review Alternatives
  • ? ? Sedative Trial

31
Nasal CPAP Problem 2
  • Claustrophobia
  • ? Less obtrusive interface
  • ? Wake time desensitization

32
Nasal CPAP Problem 3
  • Pressure Intolerance
  • ? Temporary Reduction
  • ? Expiratory Pressure Reduction
  • ? Sleep State Reduction
  • ? Auto-Titrating Systems
  • ? Bi-Level Pressure

33
Nasal CPAP Problem 4
  • Persistent Daytime Symptoms
  • ? Confirm pressure setting
  • ? Increase duration of use
  • ? ? System/Mouth leak
  • ? Chin Strap
  • ? Consider Full Face Mask
  • ? Stimulant Therapy (Modafinil Armodafinil)

34
Nasal CPAP Problem 5
  • Nasal/Oral Mucosal Problems
  • 1. Dryness
  • Nasal dryness ? Heated humidifier
  • Oral dryness ? Treat mouth leak
  • 2. Irritation/Hypersecretion
  • Heated humidification
  • Nasal steroids/Saline Rinse

35
For More Info www.smaminfo.com
36
References
  • Allam JS, Olson EJ, Gay PC, Morgenthaler TI.
  • Efficacy of adaptive servoventilation in
    treatment of complex and central sleep apnea
    syndromes.
  • Chest. 2007 Dec 132 (6) 1839-1846.
  • PMID 18079219 PubMed indexed for MEDLINE
  • Bradley TD.
  • CPAP should be used for central sleep apnea in
    congestive heart failure patients.
  • J Clin Sleep Med. 2006 Oct 152 (4) 394-398.
  • PMID 17557465 PubMed indexed for MEDLINE
  • 3. Brown LK, Casey KR.
  • Complex sleep apnea the hedgehog and the fox.
  • Curr Opin Pulm Med. 2007 Nov 13 (6) 473-478.
  • PMID 17901751 PubMed indexed for MEDLINE
  • Dernaika T, Tawk M, Nazir S, Younis W,
    Kinasewitz GT.
  • The significance and outcome of continuous
    positive airway pressure-related central sleep
    apnea during split-night sleep studies.
  • Chest. 2007 Jul 132 (1) 81-87. Epub 2007
    May 2.

37
References
  • Gay PC.
  • Complex Sleep Apnea It Really Is A Disease.
  • Journal of Clinical Sleep Medicine. 2008 Vol
    4. No.5
  • 7. Gilmartin GS, Daly RW, Thomas RJ.
  • Recognition and management of complex
    sleep-disordered breathing.
  • Curr Opin Pulm Med. 2005 Nov 11 (6) 485-493.
    Review.
  • PMID 16217173 PubMed indexed for MEDLINE
  • 8. Javaheri S.
  • Acetazolamide improves central sleep apnea in
    heart failure a double-blind, prospective study.
  • Am J Respir Crit Care Med. 2006 Jan 15 173
    (2) 234-237. Epub 2005 Oct 20.
  • PMID 16239622 PubMed indexed for MEDLINE
  • Javaheri, MD.
  • The Prevalence and Natural History of Complex
    Sleep Apnea.
  • Journal of Clinical Sleep Medicine. 2009 Vol
    5. No3

38
References
  • 11. Kuzniar TJ, Pusalavidyasagar S, Gay PC,
    Morgenthaler TI.
  • Natural course of complex sleep apnea a
    retrospective study.
  • Sleep Breath. 2007 Sept 15 (Epub ahead of
    print)
  • PMID 17874254 PubMed as supplied by
    publisher
  • 12. Lehman S, Antic NA, Thompson C, Catcheside
    PG, Mercer J, McEvoy RD.
  • Central sleep apnea on commencement of
    continuous positive airway pressure in patients
    with a primary diagnosis of obstructive sleep
    apnea-hypopnea.
  • J Clin Sleep Med. 2007 Aug 15 3 (5) 462-466.
  • PMID 17803008 PubMed indexed for MEDLINE
  • Malhotra A.
  • Complex Sleep Apnea It Isnt Really A Disease.
  • Journal of Clinical Sleep Apnea. 2008 Vol 4.
    No.5
  • 14. Morgenthaler TI, Gay PC, Gordon N, Brown
    LK.
  • Adaptive servoventilation versus noninvasive
    positive pressure ventilation for central, mixed,
    and complex sleep apnea syndromes.
  • Sleep. 2007 Apr 1 30 (4) 468-475.
  • PMID 17520791 PubMed indexed for MEDLINE

39
References
  • 16. Papacostas SS, Myrianthopoulou P, Dietis A,
    Papathanasiou ES.
  • Induction of central-type sleep apnea by vagus
    nerve stimulation.
  • Electromyogr Clin Neurophysio. 2007 Jan-Feb 47
    (1) 61-63.
  • PMID 17375884 PubMed indexed for MEDLINE
  • 17. Pusalavidyasagar SS, Olson EJ, Gay PC,
    Morgenthaler TI.
  • Treatment of complex sleep apnea syndrome a
    retrospective comparative review.
  • Sleep Med. 2006 Sept 7 (6) 474-479. Epub
    2006 Aug 23.
  • PMID 16931153 PubMed indexed for MEDLINE
  • 18. Thomas RJ.
  • Effect of added dead space to positive airway
    pressure for treatment of complex
    sleep-disordered breathing.
  • Sleep Med. 2005 Mar 6 (2) 177-178. Epub
    2005 Jan 25.
  • PMID 15716223 PubMed indexed for MEDLINE
  • 19. Wang D, Teichtahl H, Drummer O, Goodman C,
    Cherry G, Cunnington D, Kronborgl
  • Central sleep apnea in stable methadone
    maintenance treatment patients.
  • Chest. 2005 Sept 128 (3) 1348-1356.
  • PMID 16162728 PubMed indexed for MEDLINE

40
References
  • 20. Yumino D, Bradley TD.
  • Central sleep apnea and cheyne-stokes
    respiration.
  • Proc Am Thorac Soc. 2008 Feb 5 (2) 226-236.
  • PMID 18250216 PubMed in process
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