Treatment of - PowerPoint Presentation

Slide1

Treatment of Obstructive Sleep ApneaA multidisciplinary approach

Ghazala Farooqui, MDSlide2

Disclosure StatementSlide3

ObjectivesChoose an appropriate strategy for patientsModify strategy according to need/tolerance Increase long term complianceImprove overall healthSlide4

Treatment ChallengesNon ComplianceCost

Patient awareness

Rx failure

Lifestyle adjustment

↑TimeSlide5

UA Collapsibility >>>

Muscle Control

& Function

Arousal Threshold

Loop GainSlide6

Upper Airway Collapsibility

Reduced airway lumen in OSA vs non OSA

Obesity – narrowing due to fat deposition

Carniopharangeal

featureSlide7

Case45 Y.O ♂ sent by wifeCC : falling asleep while driving. ? SnoringPMH / SH : Not alarming

Physical Exam

BMI : 50 kg/m², other VS are WNL

Mallampati IV

Chart Warning: “Insurance XYZ”

Home Sleep Study: AHI = 13.8/hourWhat’s Next!!!!!!! Slide8

Positive Pressure Ventilation PPV is the first – line therapy Prior to CPAP, surgery was the only optionSlide9

Invention of CPAP *Dr. Colin E Sullivan >>>>>The pioneer of CPAP

*Experimented with pressurized air machine with Vacuum Cleaner motor on dogs first

June 1980: Used CPAP on first patient with success

” I went through a series of cycles increasing the pressure

… literally

“turning off” the apnea, and then dropping the pressure

and

“turning on” the apnea. There was no uncertainty or ambiguity.

The method worked. The effect was so clear and repeatable,

the

next question to answer was would it work all night”Slide10

Invention of CPAP Five patients with severe obstructive sleep apnoea were treated with continuous positive airway pressure (CPAP) applied via a comfortable nose mask through the nares. Low levels of pressure (range 4·5-10 cm H2O) completely prevented upper airway occlusion during sleep in each patient and allowed an entire night of uninterrupted sleep. Continuous positive airway pressure applied in this manner provides a pneumatic splint for the nasopharyngeal airway and is a safe, simple treatment for the obstructive sleep

apnoea

syndrome

.

***Lancet 1981; 1:862-5Slide11

*** Selective Indication of PAP in SDB with obstruction. GMS Currnt topics in otolarygology;2006 Slide12

Evolution of PAPOld Machine: 14 lbs, noisyOld Masks: Plaster molds > Fiberglass mask with holes for air tubes. Glued on face Slide13

Evolution of PAP1985: CPAP widely available in America1990: F&P introduced first humidifier. Water not heated1990: Bilevel PAP

1994:

Mirage Swift – First nasal pillow

1995:

Humidifier integrated into CPAP.

2007:

Auto CPAP

2011:

Heated tubes : combat condensation2014: AirSense CPAP with built in modem*Ramping option:

Manual vs auto

*

Comfort features:

EPR and C-FlexSlide14
Slide15

Positive Pressure VentilationImproves Sleep ApneaImproves Daytime SomnolenceImproves nocturnal hypoxemiaConsolidates Sleep Improves QOLBenefits seen in CVD, DM, Obesity

Benefits are

complinace

DEPENDENTSlide16

Compliance If non compliant, Insurances will not pay Medicare Compliance guidelines70%Min 4 hours per night30 – 90 days of initiationFace to face evaluation with physician of choiceDocumentation of Rx benefits.

25% with OSA are non complaint

*** Chest 2017; 151(3):707-719

Review of 113 studies from 1990 -2016Slide17
Slide18

Compliance Obstacles

35

% PND. 25% congestion

Nasal irrigation

Humidify

Mask fit

Desensitize

Hypnotics

Prop up

Sleep position

65% dry nose, mouth

Humidify

?

mouth breathing

Interface

Mask fit

50% reported at least one side effect

*** s/e of nasal CPAP in SAS. Chest 1995;107:375-81Slide19

Interface

FFM: 10% -25%

4/5 RCTs - ↑ leaks

Pillows: 10% pt.

Nasal mask

Oral: rarely used

Fixed vs Auto CPAP

4/6 RTCs did not show significant difference in leaks

CPAP/C-Flex/APAP

No difference in leaks

Chin Strap

Reduces leaks

Long term tolerance ??

*** Chest 2017; 151(3):707-719

Review of 113 studies from 1990 -2016Slide20

Conservative Approach

**JCSM, Vol. 11, No. 2, 2015

Positional Therapy

Tennis ball, collars, pillows

Short term compliance with mild AHI

Poor long term compliance.

Likely ineffective in moderate to severe OSA.

Weight Loss

OSA

prevelance

: 45% in obese

Fat in neck, trunk and viscera

1 unit reduction in BMI 2.3 unit reduction in AHI

Intensive Lifestyle Intervention vs

B

ariatric

S

urgery

Pt. undergoing bariatric surgery →

>70% OSAMetaanalysis >>> Complete resolution only in 4%**Interactions Between Obesity

and Obstructive Sleep ApneaImplications for Treatment CHEST / 137 / 3 / MARCH, 2010

**Effects of surgical

weight loss on measures of obstructive sleep apnea: a

metaanalysis

,

Am J Med

. 2009 ; 122 ( 6 ): 535 - 542 .Slide21

Oral AppliancesAASM 2015 revised guidelines recommend: OA for snoring and CPAP treatment failureNo limitation on severity in 2015Better devices ?Better compliance ?Stronger evidence? Slide22

Oral AppliancesLess efficacious More acceptable, better toleranceTarget anatomical component. Protrude TongueProtrude MandibleSlide23

Am J Respir Crit Care Med Vol 163. pp 1457–1461, 2001

A Randomized, Controlled Study of a Mandibular

Advancement Splint for Obstructive Sleep Apnea

ATUL MEHTA, JIN QIAN, PETER PETOCZ, M. ALI DARENDELILER, and PETER A. CISTULLISlide24

©2017 UpToDate®Slide25
Slide26

Case45 Y.O ♂ Returns in 3 weeksCannot bear mask on his face as there is too much pressureTried using while watching TV same thing happens

NEXT STEP!!!!!

Slide27

Upper Airway SurgerySalvage therapy after Rx failure.Adjunct with CPAP and OASuccess rate 5-78%Success → ↓ 50% AHI to <20/hUPPP ↓ Pcrit by 2-3.5 cwp.Caveats: Costly, Variable response, painful, infection, bleeding, anesthsiaSlide28

Muscle Control

& FunctionSlide29

Muscle control and function

Inspiration:

Ms

Stiffen to dilate lumen

30% OSA

pt

: ↓ Ms responsivenessGenioglossus: largest dilatorSlide30

Pcrit

Adapted from Schwartz AR, Smith PL, Kashima HK, et al. Respiratory function of the upper airways. In: Murray JF, Nadel JA, eds. Textbook of respiratory medicine. 2nd ed. Philadelphia: WB Saunders, 1994; 1451-70).Slide31

Muscle control and functionSlide32

Muscle Control & Function

2001: Schwartz et al reported that stimulation of XII nerve can ↓ OSA in some

2011: First HNS device by

Apnex

Medical – out of business in 2013

2014: “Inspire” is the only FDA approved HGN stimulation device.

Expensive

Inclusion criteriaSlide33

Example of airway images from the same patient during a, b) awake endoscopy and c, d) drug-induced sedation endoscopy (DISE). a, c) At the top of the images is the posterior pharyngeal wall and at the bottom is the soft palate. b, d) At the top of the image...

Faiza

Safiruddin

et al.

Eur

Respir

J 2015;45:129-138

©2015 by European Respiratory Society

Post

Ph

wall & soft palate

Post

Ph

wall & soft palate

Post

ph

wall & Tongue base

Post

ph

wall & Tongue baseSlide34

Increases in

retropalatal

and

retrolingual

area comparing no stimulation with progressively higher levels of stimulation during drug-induced sedation endoscopy.

Faiza

Safiruddin

et al.

Eur

Respir

J 2015;45:129-138

©2015 by European Respiratory SocietySlide35

Muscle Control & FunctionHypoglossal Nerve StimulationInvasive – Cannot be 1st lineDocumentation of CPAP failure x 3 mo

AHI : 20-65/hour, <25% Mixed episodes

BMI : <32 per Inspire protocol (not FDA

req

)

Must undergo DISE

Excluded Complete Concentric Collapse at

velopharynx

Caveat: Turn on every night, Remove for MRIsSlide36

Muscle Control & FunctionContd: Hypoglossal Nerve Stimulation30 minutes to fall asleep – Rx gradually adminDry mouth, bleeding, nerve damge

, speaking trouble

Stimulation Therapy for Apnea Reduction (STAR) trial

126 patients over 36 monthsSlide37

Muscle Control & FunctionMuscle TrainingOropharyngeal training ↓ AHI by 50% & 2.5%↑SPO2 nadirImprovement in snoring Improvement in ESS by 45%Mechanism: ? ↓ tongue fat →↓ collapse, ↑ Pharynx lumen

OR

Does it change

Ms

properties and dynamics?

Need more studies and data

**Camacho M,

Certal V, Abdullatif J, et al. Myofunctional therapy to treat obstructive sleep apnea: a systematic review and meta-analysis. Sleep. 2015;38(5):669-675.Slide38

Low Arousal ThresholdSlide39

Low Arousal ThresholdBrain stem tracks – Lung vol, Airflow resistance, O2, PCO2, pH →

Resp

Arousal Threshold

RAT

in general are protective >>>

Ms

tone to wake state

↑ RAT persons can make adjustment without waking up

RAT are disruptive if out of sync or low30-50% OSA patient have low RAT – prevent adequate recruitment of upper airway muscles.Dilators MUST be

recriutable

Person MUST be asleep during recruitment processSlide40

Arousal ThresholdA low arousal threshold →premature arousal with inadequate time to accumulate respiratory stimuli (CO2 and neg pressure)A high arousal threshold

→ substantial

hypoxemia and hypercapnia with end-organ impact

Question: Should it be manipulated?

Answer: Yes, No, May be, Perhaps

Saboisky

et al. Thorax 2010Slide41

Delaying arousal may allow time for UA muscles to ↑UA muscles are necessary and sufficient to stabilize breathing (SLEEP 2009)Sedatives can prevent state instability (Younes et al SLEEP 2007, Park

et al SLEEP

2008)

Eszopiclone

and Trazodone ↑RAT to –

ve

pressure and can ↓AHI by 25-50% without increasing hypoxemia

Std. doses of Temazepam

, Zopiclone, Zolpidem →Ø effect on genioglossus activity.Zolpidem → Genioglossuss activitiy ↑ 3x

RISKS: Hypoxemia, tolerance , withdrawal, addiction

Arousal Threshold

Carberry JC, Fisher LP,

Grunstein

RR, et al. Effects of hypnotics

on the

phenotypic causes of

OSA . AJRCCM 2017;195:A7531

.

Eckert DJ

,

et al.

Eszopiclone

increases

the respiratory

arousal threshold and lowers the

AHI in OSA patients

with a low arousal

threshold.

Clin

Sci. 2011;120(12):505-514

.

Smales

ET

,

et al. Trazodone effects

on OSA and

non-REM arousal threshold. Ann

Am

Thorac

Soc.

015;12(5

):758-764.Slide42

Loop GainSlide43

Loop GainLoop Gain = _ Ventilatory Response__ Ventilatory Disturbance

Loop Gain determines stability/

unstability

Loop Gain

Chemosnsitivity+Chemoresponsiveness

(↑pCO2, ↓pO2)

Efficiency of CO2 excretion

Circulatory Delay

Usually constant except in CHFSlide44

Loop Gain↑ Loop Gain - ↑ vent response to small ∆ pCo2→ Hypocanpnea & ↓resp. driveSeen in 30% OSA fluctuations in ventilatory drive (due to ventilatory

control instability) can lead to upper airway instability and potentially collapse at the nadir of

ventilatory

drive (

the airway tends to collapse when

ventilatory

drive to the muscles drops below 1 L/min.

Resp Physiol Neurobi. 200 July 31; 162(2) 144-151Slide45

Loop GainOxygenO2 stabilizes Vent –50%↓ AHI, 50% ↓ LGLimitations: Not in practice. CPAP can achieve oxygenation in most patients

Carbonic

Anhydraze

Inhibitors

Acetazolamide 500 mg BID x1

wk

40% ↓ in LG with OSA.

50% ↓ in non REM AHI

Limitations: dry mouth, dizzinessSlide46

Case45 days follow up visitStill sleepy but not that muchCompliance: 95%. No leaks What Now!!!

Consider Stimulants

Weight loss- Should be a goal right from

first encounterSlide47

47

Thank you for your attentionSlide48