S|eep ke|ated kesp|ratory hys|o|ogy

and S|eep D|sordered 8reath|ng

nell lreedman, Mu
ACC ulmonary 8oard 8evlew 2013


D|sc|osures
l Pave no ConlcLs of lnLeresL
A8IM u|monary 8oard 8|uepr|nt
Sleep 8esplraLory (8)
(13-13 Cuesuons ln Lhe followlng areas)
normal physlology, sleep and resplrauon
CenLral sleep apnea
CbsLrucuve sleep apnea
Sleep hypovenulauon
nocLurnal asLhma
Cb[ecnves
uescrlbe Lhe normal changes ln resplraLory
physlology durlng sleep
uene Lhe consequences of obsLrucuve sleep apnea
(CSA) and llsL poLenual LreaLmenL opuons
CuLllne Lhe characLerlsuc ndlngs of cheyne sLokes
cenLral sleep apnea and deLermlne lnlual LreaLmenL
ldenufy characLerlsucs of Lhe obeslLy hypovenulauon
syndrome
ulerenuaLe sleep relaLed changes ln pauenLs wlLh
CCu and asLhma
Lecture Cut||ne
normal sleep overvlew
normal sleep relaLed resplraLory physlology
CbsLrucuve sleep apnea
CenLral sleep apnea
Sleep relaLed hypovenulauon
Sleep and oLher pulmonary dlseases
Norma| Adu|t S|eep
non-8LM SLages 1 - 3
SLages 1 - 3 (llghL Lhrough deep sleep)
73 of LoLal sleep ume (1S1)
Ma[orlLy ls sLage 2

8LM (8apld Lye MovemenL)/uream sleep
23 of LoLal sleep ume
Cycles every 90 - 120 mlnuLes
Ma[orlLy occurs ln early mornlng (3 - 7 AM)
Norma| Changes |n Adu|t S|eep w|th Ag|ng
Less deep sleep (SLage 3)
Lspeclally ln men and Lhose over 60
More llghL sleep (SLage 1)
lncreased awakenlngs
8ody clock shls earller
Larller sleep ume and awakenlng ume
8LM sleep remalns relauvely consLanL
13 - 23 of LoLal sleep ume
Changes |n kesp|ranon dur|ng S|eep:
Cverv|ew
uecrease ln mlnuLe venulauon: 0.3 Lo 1.3 L/mln
lncrease ln alrway reslsLance
uecrease ln meLabollc raLe (CC
2
producuon) by 10
Lo 13
uecrease responses Lo CC
2
and oxygen ln n8LM and
furLher ln 8LM sleep:
uecrease aC
2
: 3 Lo 10 mm Pg
uecrease oxygen saLurauon: 2
lncrease aCC
2
: 2 Lo 8 mm Pg
8
kesponse to nypox|a: Awake vs S|eep

100 90 80
5
10
15
REM
Oxygen Saturation (%)
V
e
n
t
i
l
a
t
i
o
n

(
L
/
m
i
n
)

Awake
3/4
2
uouglas n!. Clln ChesL Med 1983,6:363
rlnclples and racuce of Sleep Med 2010
venulaLory response Lo
hypoxla decreases ln
healLhy adulLs ln n8LM
and 8LM sleep.

uecrease ln n8LM sleep
may be greaLer for men
vs women.

uecreased hypoxlc response
ln 8LM slmllar beLween
genders.

lrequency of arousals noL
relaLed Lo degree of nlghmme
hypoxla.

Venn|atory kesponse to CC2 and
S|eep
venulaLory response Lo CC
2
ls
decreased ln n8LM sleep.

Slope of Lhe response llne ls
furLher decreased ln 8LM sleep.

SeL polnL for response Lo CC
2

lncreases durlng n8LM sleep and
furLher ln 8LM sleep.
8equlres a hlgher aCC
2
Lo
sumulaLe resplrauon
30 40 50
20


10


0
End-tidal PCO
2
(mmHg)
V
e
n
t
i
l
a
t
i
o
n

(
L
/
m
i
n
)

Awake
Stage 3/4
Stage 2
REM
uouglas n! Clln ChesL Med 1983
kesp|ranon Dur|ng kLM S|eep
venulauon
8educuon ln udal volume by up Lo 40
8reaLhlng ls regular durlng Lonlc 8LM sleep
auern changes ln relauonshlp Lo eye movemenLs
auern mosL lrregular ln phaslc 8LM sleep
ChesL and Abdomen
uecrease ln lnLercosLal acuvlLy
lncreased dlaphragm acuvlLy
upper alrway - conLroverslal
lurLher reducuon ln C
2
saLurauon compared Lo n8LM sleep
11
Changes |n 8reath|ng Dur|ng S|eep:
1he 8ouom L|ne
Cverall reduced response Lo CC
2
and oxygen ln
n8LM wlLh furLher reducuons ln 8LM sleep
n8LM sleep characLerlzed by regular breaLhlng and
lncreased upper alrway reslsLance
8LM sleep characLerlzed by:
lrregular breaLhlng durlng phaslc 8LM sleep
8educed muscle Lone and mlnuLe venulauon
lurLher reduced response Lo CC
2
and oxygen
C8S1kUC1IVL SLLL ANLA (CSA)
Cbstrucnve S|eep Apnea (CSA):
Cbstrucnve Apneas
1herm
8ecurrenL CbsLrucuve Apneas
wlLh AssoclaLed Cxygen uesaLurauons
Measures of S|eep Apnea Irequency
Apnea Index
# apneas per hour of sleep
Apnea ] nypopnea Index (AnI)
# apneas + hypopneas per hour of sleep
kesp|ratory D|sturbance Index (kDI)
# apneas + hypopneas + 8L8As per hour of sleep
15
Sever|ty: Dehn|non (Arb|trary)








16
SeverlLy
Apnea Pypopnea lndex
(APl)
normal < 3
Mlld CSA 3-14
ModeraLe CSA 13-29
Severe CSA > 30
Lp|dem|o|ogy
revalence:
3 Lo 10 of adulLs ln wesLern counLrles
As common as asLhma
8lsk lncreases by abouL 2 per year
revalence lncreases wlLh age

S|eep Apnea |s as Common as Asthma and
More Common w|th Age
Age (yrs)

o
f

o
p
u
l
a
u
o
n

w
l
L
h

S
l
e
e
p

A
p
n
e
a

Young, TB et al. Arch Intern Med. 2002;162:893
Men at Greater k|sk
(Up to Age S0)
M
a
l
e

8
l
s
k

o
f

S
l
e
e
p

A
p
n
e
a


v
s

l
e
m
a
l
e

Age
1lshler, v. !AMA 2003
Lxcess We|ght Increases k|sk
(Up to Age 60)
8
l
s
k

o
f

S
l
e
e
p

A
p
n
e
a

Age
1lshler, . !AMA 2003
CSA k|sk Iactors
Age
Men (up Lo age 30)
osLmenopausal sLaLe
8lsk beLween genders slmllar aer menopause
CverwelghL and obeslLy (up Lo age 60)
LLhnlclLy
Afrlcan Amerlcan, Aslan, or Plspanlc
upper alrway anaLomlc obsLrucuon
Medlcal problems:
Congesuve hearL fallure, hlsLory of a sLroke, kldney fallure

CSA Consequences
CSA:
Why We
Care
Cv ulsease
neurocognluve
ueclLs
uayume
sleeplness
and
MvAs
uepresslon
and
Mood
ulsorders
8educed
CuallLy of
Llfe
CSA Increases k|sks for
Card|ovascu|ar D|sease
lncreased rlsk facLor for:
Plgh blood pressure
PearL auacks
SLroke
Sudden deaLh
May worsen:
PearL fallure and dlabeLes
May make us or keep us overwelghL
8lsk ls dependenL on severlLy (APl) of CSA and degree of
oxygen desaLurauon
8lsk ued more Lo degree of oxygen desaLurauon Lhan APl
8lsk of deaLh from CSA decreases aer age 63

Daynme S|eep|ness
MosL common pauenL sympLom
8esulLs from sleep fragmenLauon
uoes noL need Lo be presenL !!!!!
Lven ln severe dlsease
30 wlLh mosL severe sleep apnea are noL sleepy
Sull aL rlsk for cardlovascular compllcauons
Cther Consequences
Memory and concenLrauon problems
May worsen depresslon
Worse quallLy of llfe
Sexual dysfuncuon
Sleep problems for bed parLner
lncreased rlsk of auLo accldenLs
lncreased uullzauon of healLh care
key olnL:
ulmonary P1n ls noL common ln CSA
When presenL, should conslder oLher euologles
CSA DIAGNCSIS
26
n|story and hys|ca| Lxam A|one Not
D|agnosnc |n Many Cases
Many pauenLs won'L have sympLoms!
> 30 won'L complaln of sleeplness
Some pauenLs dene Lhelr sympLoms dlerenLly
key polnL: 1he absence of dayume sympLoms does noL
rule ouL Lhe dlsease
8ed parLner hlsLory of snorlng and wlLnessed apneas:
osluve predlcuve value of 64
WlLnessed apneas besL hlsLorlcal predlcLor
LxperL healLhcare provlder sub[ecuve lmpresslon:
CorrecLly ldenues only 30 of sleep apnea pauenLs
Cb[ecnve D|agnos|s of CSA
CvernlghL sleep sLudy (olysomnography) - Pas been consldered Lhe gold
sLandard
> 3 evenLs/hour wlLh sympLoms
> 13 evenLs/ hour wlLh or wlLhouL sympLoms
orLable Lesung ls here Lo sLay and wlll llkely become Lhe sLandard meLhod of
dlagnosls for uncompllcaLed CSA
8esL devlce ls noL clear
lndlcaLed for pauenLs wlLh a hlgh cllnlcal susplclon of moderaLe Lo severe CSA
wlLhouL assoclaLed comorbldlues
Comorbld medlcal dlsorders: CPl, hypovenulauon syndromes, CCu,
sLroke
Comorbld sleep dlsorders: lnsomnla, resLless legs syndrome, narcolepsy
CLher meLhods noL proven or recommended:
nocLurnal oxlmeLry
AuLoA (AA)
Who Shou|d be 1reated for CSA?
ModeraLe Lo severe CSA wlLh or wlLhouL sympLoms
ModeraLe CSA: APl = 13 Lo 29 evenLs per hour
Severe CSA: APl > 30 evenLs per hour
Mlld CSA wlLh sympLoms:
Mlld CSA: APl = 3 Lo 14 evenLs per hour
SympLoms:
uayume sleeplness, depresslon, mood dlsorders,
memory problems, P1n, any Cv dlsease
1reatments for CSA
Avoldance of alcohol, sedauves and narcoucs
osluon Lherapy
Should be used ln comblnauon wlLh a prlmary LreaLmenL
WelghL loss
Conunuous posluve alrway pressure (CA)
CLher - 8llevel, AuLoA (AA)
Cral appllance
Surgery
We|ght Loss Improves CSA:
8est Data 8ased on 8ar|atr|c Surgery
8Ml lmproves
33.3 Lo 37.7 kg/m
2

APl lmproves
34.7 Lo 13.8
8esldual dlsease ln
ma[orlLy
APl < 10 ln 44
APl < 3 ln 23
Creenburg eL al. Am ! Med. 2009,122(6):333-42
Connnuous os|nve A|rway ressure
(CA)
lnlually descrlbed by Sulllvan ln 1981
CurrenLly Lhe malnsLay of Lherapy for CSAS
Case 1
A 43 year old obese male presenLs wlLh snorlng,
wlLness apneas and dayume sleeplness
MPx: P1n, depresslon, aLrlal brlllauon and uM
Pe undergoes a polysomnography (SC) LhaL
demonsLraLes severe CSA (APl = 40)
Pe ls lnluaLed on CA Lherapy aer an ln lab CA
uLrauon and reLurns 4 weeks laLer for an evaluauon
uesnon 1
Whlch one of Lhe followlng ouLcomes would be mosL
llkely Lo lmprove wlLh CA Lherapy?

A) PyperLenslon
8) uayume sleeplness
C) Mood (depresslon)
u) ALrlal brlllauon
AASM racnce arameter and C||n|ca|
Gu|de||ne kecommendanons Sn|| Supported by
the Data
CA lndlcauons (SLandards):
- 1reaLmenL of moderaLe - severe CSA
- lmprovlng sub[ecuve sleeplness
CA 8ecommendauons (Cpuons):
- 1reaLmenL of mlld CSA
- lmprovlng quallLy of llfe
- As an ad[uncuve anu-hyperLenslve Lherapy
Kushida, C et al. Sleep 2006; 29:375-380
Gay, P et al. Sleep 2006;29:381- 401
Epstein, L et al. J Clin Sleep Med 2009;5:263-276
CA Cutcomes Summary:
keducnons |n AnI and Improved Daynme S|eep|ness
Most Cons|stent Cutcomes
APl
Sleep
ArchlLecLure
Sub[ecuve
Sleeplness
Cb[ecuve
Sleeplness
neuro-
cognluve
and Mood
CuallLy
of Llfe
Cardlovascular
8lsk 8educuon
Severe
CSAS
+ +/- + +/- +/- +/- +/-
Mlld/
ModeraLe
CSAS
+ +/- +/- - +/- +/- +/-
Kushida, C et al. Sleep 2006; 29:375-80
Gay, P et al. Sleep 2006;29:381- 401
CSA, CV D|sease and 1reatment (CA):
1he 8ouom L|ne: Data |s Inconc|us|ve
CA may reduce cardlovascular morLallLy
- rospecuve observauonal sLudles
CA can reduce blood pressure, buL reducuons ln 8
are small and resulLs are lnconslsLenL across sLudles
- uayume sleeplness may predlcL more robusL 8 response
- 8euer compllance = 8euer 8 response
- AnuhyperLenslve medlcauon beuer Lhan CA
LlmlLed daLa for reducuons of arrhyLhmlas wlLh CA
CA lmproves LvLl ln pauenLs wlLh CPl and CSAS
Mlnlmal Lo no daLa concernlng:
- Mlld CSAS
- Long-Lerm 8C1s on oLher cardlovascular ouLcomes
CA Comp||ance
uenluon: ?
> 4 hours on 70 of observed nlghLs
Cb[ecuve compllance 30 - 60
MosL people overesumaLe Lhelr compllance
Average nlghLly use only 4 Lo 3 hours
Compllance pauerns deLermlned early
redlcLors of compllance lnconslsLenL
osslbly dayume sleeplness and more severe dlsease
Lower socloeconomlc class and race assoclaLed wlLh lower compllance
ressure level noL predlcuve
AASM racnce arameters and C||n|ca|
Gu|de||ne Comp||ance kecommendanons
lnLervenuons Lo lmprove Compllance:
- PeaLed humldlcauon (SLandard)
- Lducauon (SLandard)
- Cognluve behavloral Lheraples (C81) wlLh educauon
lollow up:
- CA usage should be ob[ecuvely monlLored (SLandard)
- lnlual follow up ln rsL few weeks (SLandard)
- ?early and as needed follow-up Lhereaer (Cpuon)

Kushida, C et al. Sleep 2006; 29:375-80
Gay, P et al. Sleep 2006;29:381- 401
Epstein, L et al. J Clin Sleep Med 2009;5:263-276
Unproven Comp||ance Intervennons
8amp
no daLa
1elemedlclne
Pypnoucs
noL helpful
noL harmful (as long as CA used)
Advanced A Lechnologles
ClLLx
8llevel
AA

D|erenna| D|agnos|s for kes|dua| Daynme
S|eep|ness |n CSA on CA
Subopumal CA use
Subopumal CA use
Subopumal CA use
lnadequaLe LoLal sleep ume
oor mask L
nasal congesuon
Lxcesslve leak
lnadequaLe CA pressure
Medlcauon slde eecLs
Syndrome of resldual dayume sleeplness on CA
narcolepsy/ldlopaLhlc Pypersomnla
AA for CSA: 1he 8ouom L|ne
8ecommended for Lhe LreaLmenL of pauenLs wlLh moderaLe
Lo severe uncompllcaLed CSA
As sLand alone Lherapy or Lo seL a xed CA semng
noL recommended for:
CSA wlLh comorbldlues:
CPl, hypovenulauon syndromes, CCu, non-snorers (u)
CSA dlagnosls or spllL-nlghL sLudles
CuLcomes:
Lower mean pressures wlLh AA
Slmllar ouLcomes Lo CA
Compllance, resoluuon of CSA, dayume sleeplness
AA ls as eecuve as CA for uncompllcaLed moderaLe Lo severe CSA
8||eve| 1herapy Does Not Improve
Comp||ance |n anents w|th CSA
LlmlLed number of sLudles wlLh varlable deslgns
4 sLudles of CSA wlLhouL comorbld ux
18 arucles uslng modled crlLerla
no dlerences ln emcacy, compllance raLes or slde
eecLs ln uncompllcaLed CSAS
oLenual 8oles:
Cpuonal Lherapy for pauenL's wlLh pressure complalnLs
()

kushlda, C eL al. Sleep 2006, 29:373-380
Cay, eL al. Sleep 2006,29:381- 401
Cochrane uaL SysL 8ev 2004:4:Cu003332
Cra| App||ances for CSA
8esL for mlld Lo moderaLe sleep apnea
Can be used for pauenLs wlLh more severe dlsease who
fall CA
CA should be rsL llne Lherapy for severe dlsease
Cb[ecuve Lesung on Lherapy should be performed Lo
documenL emcacy
CuLcomes:
CA more eecuve for reduclng APl and lmprovlng
oxygenauon
CAs = CA for lmprovlng dayume sleeplness
CAs may lmprove blood pressure
MosL daLa observauonal
kushlda, C eL al. Sleep 2006,29:240-43
lerguson, k eL al. Sleep 2006,29:244-62
! Clln Sleep Med 2013,9:163-174
Surgery for CSA
Laser asslsLed uvuloplasLy (LAu) noL recommended
8esL surglcal opuons:
8arlaLrlc surgery for obese pauenLs wlLh CSA
Maxlllo-mandlbular advancemenL (MMA)
AdenoLonslllecLomy for pedlaLrlc populauon
uaLa supporung oLher upper alrway procedures
lnconslsLenL or lncompleLe
CSA: 1he 8ouom L|ne
CSA ls common, yeL underdlagnosed
revalence 3 Lo 10 and lncreases wlLh age
8lsk facLors:
Men (up Lo age 30)
Age
osLmenopausal sLaLe
CverwelghL and CbeslLy (up Lo age 60)
LLhnlclLy
Afrlcan Amerlcan, Aslan, or Plspanlc
upper alrway anaLomlc obsLrucuon
Medlcal problems:
Congesuve hearL fallure, hlsLory of a sLroke, kldney fallure
CSA D|agnos|s: 1he 8ouom L|ne
ln-lab polysomnography remalns Lhe sLandard for mosL pauenLs
orLable sleep apnea Lesung ls here Lo sLay
lndlcaLed for pauenLs wlLh a hlgh cllnlcal susplclon of moderaLe Lo severe
CSA wlLhouL assoclaLed comorbld medlcal or sleep dlsorders
PlsLory and physlcal exam alone may noL be sumclenL Lo rule ouL
an CSA dlagnosls
More Lhan 30 of pauenLs wlLh CSA do noL complaln of dayume
sleeplness
1hus Lhe absence of sleeplness does noL rule ouL Lhe dlsease
MosL pauenLs wlLh resldual dayume sleeplness who are on CA
Lherapy are elLher noncompllanL and or chronlcally sleep deprlved
48
1reatment for CSA: 1he 8ouom L|ne
CA:
use across specLrum of dlsease severlLy
8esL daLa for moderaLe and severe dlsease, especlally ln Lhose wlLh assoclaLed
dayume sleeplness
lmprovemenLs ln cardlovascular ouLcomes lnconslsLenL
Cral Appllances
8esL daLa for pauenLs wlLh mlld Lo moderaLe CSA
WelghL Loss
Can reduce APl, buL dlmculL Lo do
8esL daLa from barlaLrlc surgery
8esldual CSA common
Surgery
Maxlllomandlbular advancemenL
8arlaLrlc surgery can slgnlcanLly reduce APl, buL many sull le wlLh slgnlcanL
dlsease (APl > 13)
CLher surgerles lnconslsLenL resulLs and won'L be LesLed on boards

Centra| S|eep Apnea Syndromes:
(ICSD 2)
rlmary CenLral Sleep Apnea
CenLral Sleep Apnea due Lo a Cheyne SLokes 8reaLhlng
auern
CenLral Sleep Apnea due Lo Plgh AluLude erlodlc
8reaLhlng
CenLral Sleep Apnea due Lo Medlcal Condluon noL
Cheyne SLokes
CenLral Sleep Apnea due Lo urug or SubsLance
rlmary Sleep Apnea of lnfancy
Also: Sleep 1ransluon CenLral Apnea (non lCSu 2)
Centra| Apnea
Drop in the peak thermal sensor excursion
by 90% of baseline
Event lasts 10 seconds
Absence of inspiratory effort
1herm
Cheyne Stokes 8reath|ng auern
1herm
Cheyne Stokes 8reath|ng auern
Character|sncs
Crescendo decrescendo
pauern
Cycle durauon:
1yplcally 60-90 secs
roporuonal Lo clrculauon ume
lnversely proporuonal Lo LvLl
More common ln sLages 1 and
2 sleep
Arousal durlng hyperpnea
1yplcally durlng Lhe peak of
hyperpnea
uelayed oxygen desaLurauon

Arousa|s dur|ng nyperpnea
De|ayed Desaturanon
k|sk Iactors for the Cheyne Stokes
8reath|ng auern |n CnI
Male
Age > 60
Pypocapnea durlng wakefulness
ALrlal brlllauon
Centra| Apneas and CnI
CSA ls relauvely common (33) ln pauenLs wlLh CPl
wlLh sysLollc dysfuncuon
- 8ule of 1hlrds: 1/3 CSA, 1/3 CSA and 1/3 nelLher
AssoclaLed wlLh lncreased morbldlLy and morLallLy ln
pauenL wlLh CPl
May lead Lo sleep fragmenLauon and dayume
sleeplness
Pypocapnea
CenLral Apnea Pypoxemla
Pypervenulauon
Cheyne-Stokes:
Unstab|e Venn|atory
Contro|
n|gh
venulaLory
urlve
Increased ChemorecepLor 8esponslveness Lo CC2
Increased
ClrculaLory
1lme
Low Cxygen SLores\ulmonary Ldema
Cheyne Stoke 8reath|ng auern
Mechanlsms: Plgh Loop Caln!
- lncreased chemorecepLor responslveness Lo CC2
- lncreased venulaLory drlve
- lncreased clrculaLory ume
- uecreased oxygen sLores
8esulLs:
- Sleep fragmenLauon = LuS
- SympaLheuc acuvauon
Case 2
A 33 year old male wlLh a hlsLory of CPl (Ll 33)
presenLs wlLh sympLoms of frequenL awakenlngs and
dayume sleeplness.
Pls wlfe noLes lnLermluenL snorlng and perlods of
apnea.
Medlcauons: Carvedllol, furosemlde, dlgoxln,
poLasslum
Lxam: no dlsLress, mallampau score of 3, lungs clear
and 1+ bllaLeral LL edema
Cheyne Stokes kesp|ranon
1herm
uesnon 2
Whlch of Lhe followlng would be Lhe besL lnlual
LreaLmenL for Lhls pauenL?
A) CA
8) Cxygen
C) Adapuve servo venulauon (ASv) 8llevel
u) Ace lnhlblLor
L) AuLoCA
In|na| Cheyne Stokes
Management |n CnI
Max|m|ze Med|ca| 1herapy
CANA: CA Does Not Improve Surv|va| |n
CnI w|th redom|nant|y Centra| Apneas
ModesL lmprovemenLs:
- LvLl (2.2)
- Lxerclse Lolerance
- CaLecholamlnes
no aecL on:
- PosplLallzauons
- 1ransplanL-free survlval
LlmlLauons
8radley, 1 eL al. nL!M 2003,333:2023-33
AA Not Ind|cated for
Centra| Apneas of Any 1ype
AA only lndlcaLed for:
- uncompllcaLed moderaLe Lo severe CSA
noL lndlcaLed for:
- CPl
- Pypovenulauon
- CCu
- CbeslLy hypovenulauon
- non-snorers (s/p u)
MorganLhaler, 1l eL al. Sleep 2008,31:141-47
Adapnve Servovenn|anon (ASV) 8||eve|
1herapy not I|rst L|ne 1reatment for CnI
ASv Mechanlsm
- CreaLes a LargeL mlnuLe
venulauon
- venulaLes Lo Lhe LargeL
Ad[usLs raLe and pressure
supporL as needed
CurrenL uaLa:
- Can lmprove CA acuLely
- Some daLa ln CPl and
complex CSA
- CurrenL use noL well
dened
Cther Auempted 1reatments
for Centra| Apnea |n CnI
Cxygen
- May decrease APl and lmprove oxygen saLs
- Plgh levels (100) may worsen CPl
lnhaled CC2
- llndlngs lnconslsLenL
1heophylllne
- ShorL Lerm sLudles show decrease ln APl
aclng
- ALrlal paclng noL eecuve
- Cardlac resynchronlzauon Lherapy (C81)
1ransplanL
- lmproves CS8, buL may be delayed
Carcla-1ouchard, A eL al. ChesL 2008,133:1493-1304
1he 8ouom L|ne: Cheyne Stokes
MosL commonly assoclaLed wlLh CPl
CharacLerlsucs:
Cycle lengLh:
1yplcally 60 Lo 90 secs
roporuonal Lo clrculauon ume
lnversely proporuonal Lo LvLl
Arousal durlng hyperpnea
uelayed desaLurauon
Mechanlsms: Plgh Loop Caln!
lncreased chemorecepLor responslveness Lo CC2
lncreased venulaLory drlve
uelayed clrculaLory ume
AssoclaLed wlLh lncreased morLallLy ln CPl
lnlually managed wlLh maxlmlzed medlcal Lherapy
CLher Lheraples such as CA, ASv bllevel and oxygen may be consldered
aer medlcal Lherapy ls maxlmlzed
Comp|ex]A Lmergent Centra| Apneas
Comp|ex]A Lmergent Centra| S|eep Apnea
Complex or A emergenL CSA (CompSA)
Lmergence or perslsLence of cenLral apneas or hypopneas
upon exposure Lo CA when obsLrucuve evenLs have
dlsappeared
MosL pauenLs have predomlnanLly obsLrucuve or
mlxed apneas aL basellne
Cccur predomlnanLly ln n8LM sleep and ln Lhe
suplne posluon
aLhophyslology noL well dened
Comp|ex]A Lmergent Centra| S|eep
Apnea: 1he 8ouom L|ne
revalence and naLural hlsLory noL well dened
revalence = 3 Lo 20
1.3 wlLh long-Lerm reslsLanL cenLral apneas
Cpumal LreaLmenL noL well dened
no cllnlcal pracuce guldellnes Lo dlrecL Lherapy
SponLaneously resolves ln mosL lndlvlduals over ume
ln Lhe lab: 8educe A pressure rsL!
CuL of lab LreaLmenL opuons:
Addluonal LreaLmenL may noL be needed
ASv bllevel Lherapy for sympLomauc pauenLs
8ole of ASv bllevel Lherapy ls noL clear
A|ntude CSA]er|od|c 8reath|ng
n8LM assoclaLed CSA
1yplcally does noL occur below 2300 meLers
lncreased prevalence aL hlgher aluLudes
May occur aL lower aluLudes wlLh comorbldlues
Mechanlsm:
Pypoxemla
More common ln pauenLs wlLh enhanced venulaLory responses
Lo hypoxemla and hypercapnea
ShorLer cycle lengLh Lhan cheyne sLokes
1reaLmenL:
Cxygen
AceLazolamlde
Cp|o|d ke|ated S|eep D|sordered
8reath|ng: 1he 8ouom L|ne
Cplold relaLed sleep dlsordered breaLhlng:
CenLral apneas lncludlng 8loL's pauern
rolonged obsLrucuve hypovenulauon
CbsLrucuve apneas and hypopneas
Mlxed pauern of sleep dlsordered breaLhlng
MosL commonly assoclaLed wlLh long acung oplolds,
meLhadone mosL common
uose dependenL relauonshlp wlLh narcoucs
1yplcally does noL resolve sponLaneously
Cpumal LreaLmenL noL clear
May respond besL Lo a reducuon ln dose of oplolds
ASv bllevel LreaLmenL daLa lnconslsLenL
S|eep ke|ated nypovenn|anon
AASM 2012 Scorlng Manual: AdulLs
Sleep relaLed hypovenulauon denluon:
lncrease of aCC2 or surrogaLe Lo value > 33 mm Pg for > 10
mlnuLes or
lncrease of aCC2 or surrogaLe durlng sleep (ln comparlson
Lo awake suplne value) Lo a value > 30 mm Pg for > 10
mlnuLes
Cxygen desaLurauon ln Lhe absence of obsLrucuve evenLs
alone ls noL adequaLe for dlagnosls
8ecommended for Lhe deLecuon of hypovenulauon
ulagnosuc sLudy: ArLerlal aCC2, LranscuLaneous or end-udal CC2
A uLrauon: ArLerlal aCC2 or LranscuLaneous CC2
Cbes|ty nypovenn|anon Syndrome (CnS)
ulagnosls:
8Ml > 30 kg/m
2
More common wlLh lncreased obeslLy
Seen ln 23 of lndlvlduals wlLh 8Ml > 40 kg/m
2
LlevaLed awake aCC2 (> 43 mm Pg)
unable Lo aurlbuLe Lo oLher euologles of hypovenulauon
Mechanlsms unclear:
uecreased chesL wall compllance
LlevaLed alrway reslsLance
LlevaLed lepun levels assoclaLed wlLh rlsk for hypercapnea
SLronger predlcLor of hypercapnea Lhan 8Ml, vlLal capaclLy and vlsceral/subcuLaneous
faL
CSA common: Seen ln 90 of CPS
ulmonary P1n more common ln CPS Lhan CSA
1reaLmenL: A, oxygen, welghL loss
CA uLraLed ln lab wlLh or wlLhouL oxygen besL lnlual Lherapy
8llevel may be helpful when perslsLenL hypoxemla exlsLs
AA noL lndlcaLed
74
Chron|c Cbstrucnve
u|monary D|sease (CCD)
uenluon:
CbsLrucuve lung dlsease: lLv1/lvC < 70
Chronlc bronchlus:
Chronlc producuve cough for Lhree monLhs ln each of Lwo successlve years ln
a pauenL ln whom oLher causes of chronlc cough have been excluded
Lmphysema
Lmphysema ls dened by abnormal and permanenL enlargemenL of Lhe
alrspaces LhaL are dlsLal Lo Lhe Lermlnal bronchloles. 1hls ls accompanled by
desLrucuon of Lhe alrspace walls, wlLhouL obvlous brosls
AsLhma (chronlc obsLrucuve)
CCD
Luologles of sleep dlsLurbances:
Cen mulufacLorlal
nocLurnal coughlng, wheezlng, dyspnea and or orLhopnea
lncreased work of breaLhlng
Medlcauon use
Pypoxemla
S|eep ke|ated nypoxem|a |n CCD
Mechan|sms
Pypovenulauon
MosL lmporLanL mechanlsm
uecreased mlnuLe venulauon
and udal volume
8LM > n8LM > Wake
uecreased response Lo CC2 and
hypoxemla
8LM > n8LM > Wake
lncrease ln upper alrway
reslsLance
8educuon ln l8C assoclaLed wlLh
sleep and suplne posluon
v/C mlsmaLch
Determ|nants of nypoxem|a
j SaC2 durlng wakefulness
Ma[or predlcLor of mean and lowesL
saLs durlng sleep ln CCu
^ aCC2 durlng wakefulness
^ uurauon of 8LM sleep
^ SeverlLy of obsLrucuon
^ 8esplraLory muscle
dysfuncuon
^ 8Ml
Co-exlsLence of CSA
CCD: Cvern|ght Cx|metry
Courtesy Jim Parish, MD
NREM NREM NREM NREM
REM REM REM REM
CCD: SG vs Cx|metry
ln lab SC lndlcaLed when concomlLanL CSA
suspecLed
Pome sleep apnea Lesung noL lndlcaLed
CvernlghL oxlmeLry:
Pypercapnla durlng wakefulness
uayume hypoxemla
ulmonary and sysLemlc hyperLenslon
8lghL hearL fallure
CCD 1reatment
lnhalers, pulmonary rehab per CCLu guldellne recommendauons
Cxygen:
lmproves survlval ln pauenLs wlLh resung hypoxemla (aC2 < 60 mm Pg)
More (durauon) = 8euer ouLcomes
nocLurnal Cxygen 1herapy 1rlal (nC11)
Medlcal Councll 8esearch (M8C) 1rlal
CurrenL lndlcauons for Cxygen:
ArLerlal C2 (aC2) less Lhan or equal Lo 33 mmPg, or an arLerlal oxygen saLurauon (SaC2) less Lhan or equal Lo
88 percenL.
aC2 less Lhan or equal Lo 39 mmPg, or an SaC2 less Lhan or equal Lo 89 percenL, lf Lhere ls evldence of cor
pulmonale, rlghL hearL fallure, or eryLhrocyLosls (hemaLocrlL > 33 percenL).
Pypnoucs:
Avold benzodlazeplnes and non-8Zu recepLor agonlsLs lf you can
8amelLeon may be safer
1 8C1 sLudy wlLh lmproved sleep emclency and no aecL on saLs or APl
nC11 1rlal. Ann lnLern Med 1980,93:391
M8C 1rlal. LanceL 1981,1:681
Stege Resp Med 2008;102:801-814
Kryger, Sleep Breath 2009;13:79-84
Cver|ap Syndrome
CoexlsLence of CCu and CSA
revalence of CSA slmllar Lo general populauon
lncreased rlsk of deaLh and severe CCu
exacerbauon leadlng Lo hosplLallzauon lf CSA
unLreaLed compared Lo group wlLhouL concomlLanL
CSA
8lsks of deaLh or hosplLallzauon reduced wlLh CA
LreaLmenL
CuLcomes no dlerenL Lhan CCu group alone
AA conLralndlcaLed ln pauenLs wlLh CCu
Marln, ! eL al. A!8CCM 2010,182:323-331
MorganLhaler, 1l eL al. Sleep 2008,31:141-47
CCD and S|eep: 1he 8ouom L|ne
Pypovenulauon ls Lhe mosL lmporLanL mechanlsm responslble for
sleep relaLed hypoxemla
Cxygenauon durlng wakefulness ls Lhe ma[or predlcLor of mean
and lowesL oxygen saLurauon durlng sleep ln CCu
venulaLory responses Lo CC2 and hypoxemla decrease ln n8LM
and furLher ln 8LM sleep ln normals and CCu
Cxygen lmproves survlval ln CCu wlLh hypoxemla
Conslder polysomnography for concomlLanL CSA
CSA prevalence slmllar Lo general populauon
CA lmproves survlval and decreases exacerbauons and
hosplLallzauons ln Lhose wlLh Lhe overlap syndrome
Avold hypnoucs lf posslble
8amelLeon may be besL hypnouc cholce
Nocturna| Asthma
nocLurnal sympLoms lndlcaLe sub-opumally LreaLed
asLhma
revalence of nlghmme asLhma sympLoms:
1 nlghL/week (74)
3 nlghLs/week (64)
nlghLly sympLoms (up Lo 40)
ulagnosls: CrlLerla noL well dened
Changes ln Ll8 vs sympLoms vs lnhaler use
SC feaLures:
no speclc SC feaLures
AsLhma auacks noL speclc Lo any sleep sLage
Nocturna| Asthma:
otenna| Mechan|sms
Sleep relaLed changes
AuLonomlc nervous sysLem acuvlLy:
lncreased parasympaLheuc acuvlLy
uecreased sympaLheuc acuvlLy
Lung capaclLy
lnammaLory medlaLors
Clrcadlan changes ln corusol noL as lmporLanL
CLher dlsorders: CL8u or CSA
Clrcadlan varlablllLy ln alrow
C|rcad|an Var|anon |n Lung Iuncnon:
Norma| vs Asthma
normal:
4 Lo 8 reducuon from Lhe
peak Lo mlnlmum splromeLrlc
values.
Clrcadlan mlnlmum values
occur durlng normal sleep
perlod.
AsLhma:
up Lo a 30 reducuon from Lhe
peak Lo mlnlmum peak ow
values
PerLzel M8 eL al. 1horax 1980,33:723-738
Spengler C eL al. Am ! 8esplr CrlL Care Med 2000,162,1038-1046
lLv1
CBT
Cortisol
PEF
FVC
Nocturna| Asthma 1reatment
Avold preclplLanLs
lnhaled sLerolds (lCS) and prn beLa agonlsLs as rsL
llne Lherapy
Cpumal umlng of lCS noL well dened
Conslder Lhe addluon of LA8A Lo lnhaled sLerolds as
nexL sLep
CLher: LeukoLrlene lnhlblLor
1he role of emplrlc l Lherapy Lherapy wlLhouL CL8
sympLoms ls unclear
CSA: 1he 8ouom L|ne
8lsks:
Age, lncreased welghL, male gender, eLhnlclLy, medlcal condluons
Cender and welghL become less lmporLanL wlLh age
Adverse ouLcomes
uayume sleeplness absenL ln > 30
Absence of sleeplness does noL rule ouL dlsease
Cv rlsks assoclaLed wlLh CSA severlLy (APl) and oxygen desaLurauon
ulmonary P1n uncommon
ulagnosls:
orLable Lesung reasonable for pauenLs wlLh a hlgh cllnlcal susplclon of moderaLe Lo
severe dlsease wlLhouL assoclaLed comorbld dlsease
1reaLmenL
CA lndlcaLed for moderaLe Lo severe CSA, especlally for pauenLs wlLh dayume
sleeplness
lmprovemenLs ln cardlovascular ouLcomes lnconslsLenL
Cral appllances beuer daLa for mlld Lo moderaLe dlsease
WelghL loss assoclaLed wlLh resldual CSA
Advanced A devlces do noL lmprove compllance
1he 8ouom L|ne
1he besL lnlual LreaLmenL for cheyne sLokes CSA ls
maxlmlzed medlcal Lherapy
lmporLanL ouLcomes noL lmproved by CA, ASv or oxygen
CbeslLy hypovenulauon syndrome (CPS)
8Ml > 30 kg/m
2
, Awake aCC
2
> 43 mm Pg, absence of oLher
euologles
Lepun may play a role ln physlology
ulmonary P1n more common ln CPS Lhan CSA
CCu
Cverlap syndrome lncreases rlsk of adverse ouLcomes
CA lmproves ouLcomes
8amelLeon may be besL hypnouc cholce for lnsomnla
1hank ou