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Brian J. Bohner, M.D. Diplomate ABSM Fellow AASM Conference By The Sea September 17, 2009
Complex Sleep Apnea And 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
PMH:
1. 2. 3.
HTN Lumbar Arthritis No history or symptoms of CHF
Medications:
1. 2. 3.
Celebrex Metoprolol HCTZ
ROS:
1.
Nocturnal Reflux
Exam:
Baseline Polysomnogram
Polysomnogram Results:
Apnea Index = 21.3 Apnea + Hypopnea Index = 43.1 Total Sleep Time = 4.8 Hours O2 Saturation Nadir = 84%
Definition
Complex Sleep Apnea is a form of sleep apnea in which central apneas persist or emerge during attempts to treat obstructive events with nCPAP.
Patient Characteristics
1. > 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
Polysomnographic Characteristics
May have Evidence of Central Events on
Baseline PSG (Ref
2)
A. Behavioral
o o
B. Metabolic
1. Chemoreceptors a. Carotid Bodies b. Medulla
Y axis = pCO2
Eupnea
CO2 Reserve
Apnea Threshold
oo
2. Narrow CO2 Reserve in nREM 3. Hypoxia Further Reduces pCO2 4. Metabolic Acidosis Widens CO2 Reserve
Y axis = pCO2
Oo
REM nREM
Apnea Threshold
Apnea Threshold
Apnea Threshold
CO2 Reserve
Apnea Threshold
3. Provide Back-Up
A. Backup Rate on Therapy
Treatment Options
1. nCPAP with Permissive Flow Limitation
nCPAP Disregarding Central Events
2.
3.
4.
Supplemental O2 Medications
A. B. C. Acetazolamide Theophylline Benzodiazepines
5. 6.
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
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:
Implications
1. To OSA Patient:
5%-10% will not appropriately respond to nCPAP Cost of Alternative Therapies may be Prohibitive
2. To Sleep Centers:
Responsibility to Identify such patients and offer Treatment Modifications
Refitting
Review Alternatives ? Sedative Trial
Temporary Reduction
Expiratory Pressure Reduction
Bi-Level Pressure
2.
Irritation/Hypersecretion
Heated humidification Nasal steroids/Saline Rinse
References
1. 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; 15;2 (4): 394-398. PMID: 17557465 [PubMed indexed for MEDLINE] 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. PMID: 17475636 [PubMed indexed for MEDLINE] Eckert DJ, Jordan AS, Merchia P, Malhotra A. Central sleep apnea: Pathophysiology and treatment. Chest. 2007 Feb; 131 (2): 595-607. Review PMID: 17296668 [PubMed indexed for MEDLINE]
2.
3.
4.
5.
References
6. Gay PC. Complex Sleep Apnea: It Really Is A Disease. Journal of Clinical Sleep Medicine. 2008; Vol 4. No.5 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] 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 Kuzniar TJ, Golbin JM, Morgenthaler TI. Moving beyond empiric continuous positive airway pressure (CPAP) trials for central sleep apnea: a multi-modality titration study. Sleep Breath. 2007 Dec; 11(4): 259-266. PMID: 17541664 [PubMed in process]
7.
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10.
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] 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 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] Morgenthaler TI, Kagramanov V, Hanak V, Decker PA. Complex sleep apnea syndrome: is it a unique clinical syndrome? Sleep. 2006 Sept; 7 (6): 474-479. Epub 2006 Aug 23. PMID: 16931153 [PubMed indexed for MEDLINE]
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13.
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15.
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] 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] 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]
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18.
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]
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]