Title: Complex Sleep Apnea: And Other Treatment Challenges In Airway Pressure Therapy
1Complex Sleep ApneaAnd OtherTreatment
ChallengesIn Airway Pressure Therapy
- Brian J. Bohner, M.D.
- Diplomate ABSM
- Fellow AASM
- Conference By The Sea
- September 17, 2009
2Complex 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
3Case 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
4Baseline Polysomnogram
5Polysomnogram 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
6CPAP Titration Study
7CPAP Titration Development of Central Events
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10Classifications 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
11Complex 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.
12Patient 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
13Polysomnographic 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
14Clinical 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
15Understanding Pathophysiology Of Complex Sleep
Apnea
16Controls of Breathing AWAKE
xxx
- Behavioral
- Metabolic
- Chemoreceptors
- Carotid Bodies
- Medulla
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44
Eupnea
Y axis pCO2
CO2 Reserve
36
Apnea Threshold
17Controls 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
18Controls of Breathing During Sleep - CHF
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1. Pulmonary Afferent Receptors
xxx xxx xxx
2. Loop Gain A. Increased Response to pCO2
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B. Increased Lung to Peripheral
Chemoreceptor Circulation Time
pCO2
Apnea Threshold
19Controls 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
20Treatment 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
21Treatment 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)
22Adaptive 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
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24Respironics
- 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
25Res 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
26Patient T.Y. On ASV
27Therapy 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
28Implications
- 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
29Challenges In nCPAP Compliance
30Nasal CPAP Problem 1
- Interface Intolerance/Discomfort/Mask Removal
- ? Refitting
- ? Review Alternatives
- ? ? Sedative Trial
31Nasal CPAP Problem 2
- Claustrophobia
- ? Less obtrusive interface
- ? Wake time desensitization
32Nasal CPAP Problem 3
- Pressure Intolerance
- ? Temporary Reduction
- ? Expiratory Pressure Reduction
- ? Sleep State Reduction
- ? Auto-Titrating Systems
- ? Bi-Level Pressure
33Nasal 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)
34Nasal 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
35For More Info www.smaminfo.com
36References
- 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.
37References
- 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
38References
- 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
39References
- 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
40References
- 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