Obstructive Sleep Apnea A multidisciplinary approach Ghazala Farooqui MD Disclosure Statement Objectives Choose an appropriate strategy for patients Modify strategy according to needtolerance ID: 621013
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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-FlexSlide14Slide15
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 -2016Slide17Slide18
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®Slide25Slide26
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