1. 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

2. 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

3. What makes us breathe? The stimulus to breathe awake and asleep

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7. 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. 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. 9 Physiologic Changes in Respiratory Control with Sleep InactiveActiveTransitiona l Sleep* Stage 2Slow 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

10. What is “Central Sleep Apnea” Definition(s)

11. 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 PEARL Scoring criteria… Diagnostic criteria…. Reimbursement criteria….. May sometimes conflict with each other

12. PSG pattern recognition for central respiratory events. 12

13. Which is Periodic Breathing? Choose the Correct Image They ALL are periodic breathing but only 3 are “central events” OSA CSR CA Biots Opioids 13

14. Periodic Breathing Characteristics: waxing and waning breathing pattern Length is based on disease process causing the breathing pattern –Longer events for patients in heart failure 1 (picture A) ─50-70 second events of CSR then followed by normal respiration (waxing and waning of respiration) in patients with heart failure 1 –Shorter events in those at altitude/neurological disorders/renal failure 1 (picture B) ─20 – 40 seconds on length 1 14 20-40 sec 1 Thomas, et. al. Curr. Opin Pulm Med. 2005 A B 50-70 sec

15. Periodic Breathing Characteristics: waxing and waning breathing pattern Length is based on disease process causing the breathing pattern –Longer events for patients in heart failure 1 (picture A) ─50-70 second events of CSR then followed by normal respiration (waxing and waning of respiration) in patients with heart failure 1 –Shorter events in those at altitude/neurological disorders/renal failure 1 (picture B) ─20 – 40 seconds on length 1 15 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.

16. Why do central apneas occur?

17. Involuntary/Autonomic Control Upper airway compromise Respiratory Control Issues 17

18. PAP Therapy: Decision Making Tree OSA Drive to breathe is OK Try to breathe but can’t get enough in Drive to breathe is OK Try to breathe but can’t get enough in What would this look like on a PSG? HST? Therapy download? What would this look like on a PSG? HST? Therapy download? Impaired Gas Exchange Oxygen drops/Carbon Dioxide rises. Inadequate ventilation May or may not arouse Impaired Gas Exchange Oxygen drops/Carbon Dioxide rises. Inadequate ventilation May or may not arouse CSA Central Events Don’t breathe at all or pattern is mixed up Central Events Don’t breathe at all or pattern is mixed up Hypoventilation What would this look like on a PSG? HST? Therapy download? What would this look like on a PSG? HST? Therapy download? What would this look like on a PSG? HST? Therapy download? What would this look like on a PSG? 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 18

19. 19 OSAOSA CSA OSA Normal What do you see on the PSG? Note square wave pattern of OSA recovery breathing. Different from CSR. Oximetry patterns.

20. 20 Central or obstructive hypopnea? Likely response to CPAP? Triangular Paradoxical

21. PAP Therapy: Decision Making Tree OSA Obstructive Events Try to breathe but can’t get enough in Obstructive Events Try to breathe but can’t get enough in What would this look like on a PSG? HST? Therapy download? What would this look like on a PSG? HST? Therapy download? Impaired Gas Exchange Oxygen drops/Carbon Dioxide rises Impaired Gas Exchange Oxygen drops/Carbon Dioxide rises CSA Central Events Don’t breathe at all or pattern is mixed up Central Events Don’t breathe at all or pattern is mixed up Hypoventilation What would this look like on a PSG? HST? Therapy download? What would this look like on a PSG? HST? Therapy download? What would this look like on a PSG? HST? Therapy download? What would this look like on a PSG? HST? Therapy download? 21

22. 22 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

23. 23 < 1 cmH 2 O / min increase AVAPs Algorithm Desired VolumeVolume IPAP SettingPressure 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.

24. PAP Therapy: Decision Making Tree OSA Obstructive Events Try to breathe but can’t get enough in Obstructive Events Try to breathe but can’t get enough in What would this look like on a PSG? HST? Therapy download? What would this look like on a PSG? HST? Therapy download? Impaired Gas Exchange Oxygen drops/Carbon Dioxide rises Inadequate ventilation Impaired Gas Exchange Oxygen drops/Carbon Dioxide rises Inadequate ventilation CSA Central Events Don’t breathe at all or pattern is mixed up Central Events Don’t breathe at all or pattern is mixed up Hypoventilation What would this look like on a PSG? HST? Therapy download? What would this look like on a PSG? HST? Therapy download? What would this look like on a PSG? HST? Therapy download? What would this look like on a PSG? HST? Therapy download? 24

25. Which is Periodic Breathing? Choose the Correct Image They ALL are periodic breathing but only 3 are “central events” OSA CSR CA Biots Opioids 25

26. PAP Therapy: Decision Making Tree OSA Obstructive Events Try to breathe but can’t get enough in Obstructive Events Try to breathe but can’t get enough in What might cause this type of events? Impaired Gas Exchange Oxygen drops/Carbon Dioxide rises. Inadequate ventilation Impaired Gas Exchange Oxygen drops/Carbon Dioxide rises. Inadequate ventilation CSA Central Events Don’t breathe at all or pattern is mixed up Central Events Don’t breathe at all or pattern is mixed up Hypoventilation What might cause this type of event? What might cause this type of events? 26

27. Central Apnea Central Hypopnea Auto Servo Ventilation Volume Assured Pressure Support with Rate Noninvasive Ventilation CPAP APAP BiLevel Complex Sleep Apnea Components OSA Central SDB Hypoventilation Periodic Breathing CSR Obstructive apneas Obstructive hypopneas 27

28. PAP Therapy: Decision Making Tree OSA Obstructive Events Open the Airway Obstructive Events Open the Airway CPAP APAP Bi-level CPAP APAP Bi-level Impaired Gas Exchange Ventilate Impaired Gas Exchange Ventilate Auto Servo Ventilation Volume Assured Pressure Support w/Rate CSA Central Events Stabilize Breathing Pattern Central Events Stabilize Breathing Pattern Hypoventilation 28

29. Central Hypopneas 29 Periodic Breathing Opioid CSA OSA Hypoventilation The Bucket Theory Trauma CSA Opioid CSA Let’s talk about breathing during sleep

30. BiPAP autoSV Advanced Theory of Operation Servo Ventilation Algorithm Algorithms to match the pathologies

31. 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 31 cmH 2 0 Auto CPAP cmH 2 0 CPAP

32. 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. 32 cmH 2 0 Bi-Level cmH 2 0 Auto SV Flow pattern could look different depending on position and spontaneous vs machine breath. Why? How would this graphic look for AVAPS?

33. PAP Therapy for Patients with CSR More about Cheyne-Stokes Respiration 33 CO2 waxing and waning with under and over ventilation CO2 Stable, Breathing pattern stable, Patient breathes on own with normal variability Pressure Support Airflow Patient Airflow

34. What therapy would you need for each breathing pattern shown? Most patients will bring a unique mix of breathing patterns! OSA CSR CA Biots 34

35. Involuntary/Autonomic Control Upper airway compromise Respiratory Control Issues 35

36. The Complex Sleep Apnea Bucket List PathologiesPreferred Treatment OSACPAP, APAP Periodic BreathingaSV or AVAPS Cheyne Stokes type Periodic Breathing aSV Central Sleep ApneaaSV or AVAPS Central HypopneaaSV or AVAPS HypoventilationAVAPS CPAP emergent “Central Sleep Apnea” Depends. Check baseline PSG. May change with treatment. 36 Complicated X

37. 37 What do you see?

38. 38 AM060606 What do you see?

39. 39 What do you see? Proportionate changes in flow and effort. Likely central in nature

40. 40 AM060606 What do you see?

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42. 42 OSAOSA CSA OSA Normal What do you see? Note square wave pattern of OSA recovery breathing. Different from CSR. Note difference in oximetry pattern.

43. 43 Periodic breathing (CSR) REM Sleep Oximetry Polysomnography

44. 44 Central or obstructive hypopnea? Likely response to CPAP? Triangular Paradoxical

45. Patient Follow-up

46. 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 46

47. 47 SV algorithm works ‘on top’ of Auto EPAP AUTO EPAP Advanced technology and YOU The perfect combination! How do you think the patient’s physiology will change during the first weeks of ASV use?

48. 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.” 48

49. Pearls 49 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!

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