Pamela Minkley RRT, RPSGT, CPFT March 2013 Different Types of Central Sleep Apnea Figure out...

Pamela Minkley RRT, RPSGT, CPFT

March 2013

Different Types of Central Sleep Apnea

Figure out what’s causing it and you’ll know how to treat it!

Make Sleep a Priority

Goals and Objectives

1. Describe the physiologies of complex breathing disorders associated with CSA

2. Identify PSG respiratory patterns associated with CSA pathologies

3. List algorithms for advanced therapy devices designed to treat central breathing pathologies and patterns

3. Match patient pathologies with PAP therapy algorithms

4. Define “successful treatment”

2

What makes us breathe?The stimulus to breatheawake and asleep

7

Respiratory Physiology During Sleep

• Stimulus to breathe not the same as awake• Response to hypercarbia & hypoxemia blunted• Physiology varies NREM vs REM• Cardiovascular changes effect gas delivery and

exchange• Respiratory and cardiovascular disease disrupt

normal physiology• Some pathologic breathing patterns come and

go throughout the sleep period.

8

Normal Awake Stimulus to Breathe

• Hypercapnia– PaCO2 changes quickly– HCO3 changes slowly– Both affect the pH of the blood

• Hypoxia – SaO2 and PaO2

• Carotid and aortic bodies• Stretch, “J”, and other receptors

9

Physiologic Changes in Respiratory Control with Sleep

Inactive Active Transitional Sleep*

Stage 2 Slow Wave Sleep

REM Sleep

Metabolic

Regular

Absent

Present

Phasic

Behavior

Irregular

Absent

Decreased

Phasic

Metabolic**

Periodic

Often

Variable

Phasic

Metabolic

Regular

Rare

Mild Decrease

Phasic

Metabolic

Regular

Absent

Mild Decrease

Phasic

Non-metabolic

Irregular

Frequent

Mod. Decrease

Paradoxical

Major Influence on breathing

Pattern of breathing

Central Apneas/Hypopneas

Response to metabolic stimuli

Chest wall movement

* Transitional sleep refers to the period of sleep between wakefulness and continuous stage I sleep or established stage II sleep.** The metabolic regulation during the transition between sleep and wake is affected by an upward shift in pCO2 set point and the gain of the pCO2 response.

Patterns may change of come and go in different sleep stages making therapeutic effectiveness difficult to assess during a single titration night

What is “Central Sleep Apnea”Definition(s)

Central Sleep Apnea

• AASM central apnea events• Medicare complex sleep apnea definition

– In some descriptions uses “periodic breathing” as synonymous with CSA

• Medicare Central Sleep Apnea and Central Apnea definitions

11

PEARLScoring criteria…Diagnostic criteria….Reimbursement criteria…..

May sometimes conflict with each other

12

PSG pattern recognition for central respiratory events.

13

Which is Periodic Breathing?Choose the Correct Image

A

B

C

D

They ALL a

re

periodic

breathing

but only

3 are

“centra

l eve

nts”

OSA

CSR

CA

BiotsOpioids

Periodic Breathing• Characteristics: waxing and waning breathing pattern • Length is based on disease process causing the

breathing pattern– Longer events for patients in heart failure1 (picture A)

─ 50-70 second events of CSR then followed by normal respiration (waxing and waning of respiration) in patients with heart failure1

– Shorter events in those at altitude/neurological disorders/renal failure1 (picture B)

─ 20 – 40 seconds on length1

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20-40 sec

1 Thomas, et. al. Curr. Opin Pulm Med. 2005

A B

50-70 sec

Periodic Breathing• Characteristics: waxing and waning breathing pattern • Length is based on disease process causing the

breathing pattern– Longer events for patients in heart failure1 (picture A)

─ 50-70 second events of CSR then followed by normal respiration (waxing and waning of respiration) in patients with heart failure1

– Shorter events in those at altitude/neurological disorders/renal failure1 (picture B)

─ 20 – 40 seconds on length1

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20-40 sec

1 Thomas, et. al. Curr. Opin Pulm Med. 2005

A B

50-70 sec

How are treatments the same?- Optimize treatment for primary cause and monitor- They are all central in origin so need ventilation- They can coexist in a patient- A can sometimes mimic B and vice versa

How are the different?- Must protect against over-ventilation in A.

Why do central apneas occur?

Involuntary/Autonomic Control

Upper airway compromise

Respiratory Control Issues

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PAP Therapy: Decision Making Tree

OSA

Drive to breathe is OKTry to breathe but can’t

get enough in

What would this look like on a PSG?

HST?

Therapy download?

Impaired Gas ExchangeOxygen drops/Carbon

Dioxide rises. Inadequate ventilationMay or may not arouse

CSA

Central EventsDon’t breathe at all or

pattern is mixed up

Hypoventilation


HST?

Therapy download?


HST?

Therapy download?

Drive to breathe is inadequate to meet

metabolic needs

Fall asleep, airway becomes unstable,

apnea occurs, wake up, oxygen drops, CO2

increases, fall asleep, do it all again

Oxygen drops/CO2 rises but not as much as OSA

Sleep is fragmented

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O

S

A

CSA

OSA

Normal

What do you see on the PSG?

Note square wave pattern of OSA recovery breathing. Different from CSR.

Oximetry patterns.

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Central or obstructive hypopnea? Likely response to CPAP?

Triangular

Paradoxical

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OSA

Obstructive EventsTry to breathe but can’t

get enough in


HST?

Therapy download?


Dioxide rises

CSA


pattern is mixed up

Hypoventilation


HST?

Therapy download?


HST?

Therapy download?

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Volume and flow change slowly over time. With ASV, target will gradually lower and SV algorithms deliver CPAP pressure only

Hypoventilation would look like

THIS!

flow

PAP

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< 1 cmH2O / min increase

AVAPs Algorithm

Desired Volume Volume

IPAP Setting Pressure

Not a breath by breath change to stabilize the breathing pattern like aSV Delivers a targeted tidal volume. Focus is on ventilation not stabilizing the breathing pattern.

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OSA


get enough in


HST?

Therapy download?


Dioxide rises Inadequate ventilation

CSA


pattern is mixed up

Hypoventilation


HST?

Therapy download?


HST?

Therapy download?

25

Which is Periodic Breathing?Choose the Correct Image

A

B

C

D

They ALL a

re

periodic

breathing

but only

3 are

“centra

l eve

nts”

OSA

CSR

CA

BiotsOpioids

26


OSA


get enough in

What might cause this type of events?


Dioxide rises. Inadequate ventilation

CSA


pattern is mixed up

Hypoventilation

What might cause this type of event?

What might cause this type of events?

Central ApneaCentral Hypopnea

Auto Servo Ventilation Volume Assured Pressure

Support with Rate

Noninvasive Ventilation

CPAPAPAP

BiLevel

Complex Sleep Apnea Components

OSA Central SDB Hypoventilation

Periodic BreathingCSR

Obstructive apneas Obstructive hypopneas

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28


OSA

Obstructive EventsOpen the Airway

CPAP

APAP

Bi-level

Impaired Gas ExchangeVentilate

Auto Servo Ventilation

Volume Assured Pressure

Support w/Rate

CSA

Central EventsStabilize Breathing Pattern

Hypoventilation

Central

Hypopneas

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Periodic Breathing

Opioid CSA

OSAHypoventilation

The

Bucket

TheoryTrauma

CSAOpioidCSALet’s talk about breathing during

sleep

BiPAP autoSV Advanced

Theory of Operation

Servo Ventilation Algorithm

Algorithms to match the pathologies

PAP Therapy for Patients with OSA

• CPAP ─ One level of pressure on inspiration and exhalation─ Device may have the option to provide pressure relief in

early exhalation

• Auto titration therapy─ Device pressure is adjusted based on airway dynamics

and device algorithm

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cmH20

Auto CPAP

cmH20

CPAP

PAP Therapy for Patients with OSA/SDB

• Bi-level therapy─ One level of pressure on inspiration and lower level of

pressure on expiration. PS the same every breath

• Auto Servo Ventilation ─ Device pressure is adjusted based on airway dynamics,

patient respiratory effort and flow and device algorithm. PS varies according to need.

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cmH20

Bi-Level

cmH20

Auto SV

Flow pattern could look different depending on position and spontaneous vs machine breath. Why?

How would this graphic look for AVAPS?

PAP Therapy for Patients with CSRMore about Cheyne-Stokes Respiration

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CO2 waxing and waning with under and over ventilation

CO2 Stable , Breathing pattern stable, Patient breathes on own with normal variability

Pressure Support

Airflow

PatientAirflow

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What therapy would you need for each breathing pattern shown?

A

B

C

D

Most patients will bring a unique mix of breathing patterns!

OSA

CSR

CA

Biots

Involuntary/Autonomic Control

Upper airway compromise

Respiratory Control Issues

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The Complex Sleep Apnea Bucket List

Pathologies Preferred Treatment

OSA CPAP, APAP

Periodic Breathing aSV or AVAPS

Cheyne Stokes type Periodic Breathing

aSV

Central Sleep Apnea aSV or AVAPS

Central Hypopnea aSV or AVAPS

Hypoventilation AVAPS

CPAP emergent “Central Sleep Apnea”

Depends. Check baseline PSG. May change with treatment.

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ComplicatedX

37

What do you see?

38AM060606

What do you see?

39

What do you see?

Proportionate changes in flow and effort. Likely central in nature

40AM060606

What do you see?

42

O

S

A

CSA

OSA

Normal

What do you see?

Note square wave pattern of OSA recovery breathing. Different from CSR.

Note difference in oximetry pattern.

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Periodic breathing (CSR)

REM Sleep

Oximetry

Polysomnography

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Central or obstructive hypopnea? Likely response to CPAP?

Triangular

Paradoxical

Patient Follow-up

Titration is just the beginning of successful therapy

• Continuing clinical assessment is essential for:– Compliance and efficacy– Achieving long term benefits, lower morbidity/mortality

• Complex sleep apnea patient may be the most challenging to follow up because they have multiple, changing pathologies requiring therapy– Achieving optimal therapy and meeting patient

comfort needs can be a challenge that requires ongoing assessment of therapy device downloads and interviews with the patient

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47

SV algorithm works ‘on top’ of Auto EPAP

AUTO EPAP

Advanced technology and YOUThe perfect combination!

How do you think the patient’s physiology will change during the first weeks of ASV use?

Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain, Robert J. Farney, M.D; J Clin Sleep Med. 2008 August 15; 4(4):

311–319. – Retrospective study

• Conclusions:“Due to residual respiratory events and hypoxemia, ASV was considered insufficient therapy in these patients

• Persistence of obstructive events could be due to suboptimal pressure settings (end expiratory and/or maximal inspiratory). Residual central events could be related to fundamental differences in the pathophysiology of CSR compared to opioid induced breathing disturbances.”

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Pearls

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Complex physiology and pathology makes many patients difficult to treat.

They are a moving target.

Many times, making them BETTER THAN THEY WERE on the titration night IS a success!

In contrast to uncomplicated OSA patients titrated on CPAP, the titration

doesn’t END on the titration night. It is just

the beginning!

Pamela Minkley RRT, RPSGT, CPFT March 2013 Different Types of Central Sleep Apnea Figure out...

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