Different Types of
Central Sleep Apnea
Figure out what’s
causing it and you’ll
know how to treat it!
Pamela Minkley RRT, RPSGT, CPFT
Make Sleep a Priority
March 2013
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 breathe
awake and asleep
4
5
6
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.
7
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
8
Physiologic Changes in Respiratory Control with Sleep
Inactive
Major Influence on
breathing
Pattern of breathing
Central
Apneas/Hypopneas
Response to
metabolic stimuli
Chest wall movement
Metabolic
Active
Transitiona
l Sleep*
Stage 2
Behavior
Metabolic**
Metabolic
Metabolic
Nonmetabolic
Periodic
Regular
Regular
Irregular
Often
Rare
Absent
Frequent
Variable
Mild
Decrease
Mild
Decrease
Mod.
Decrease
Phasic
Phasic
Phasic
Paradoxical
Patterns may
change of
come and go in
Regular
Irregular
different
sleep
stages making
therapeutic
Absent
Absent
effectiveness
difficult to
assess
during
Present
Decreased
a single
titration night
Phasic
Phasic
Slow
Wave
Sleep
REM Sleep
* 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.
9
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
PEARL
Scoring criteria…
Diagnostic criteria….
Reimbursement criteria…..
May sometimes conflict with each other
11
PSG pattern recognition for central
respiratory events.
12
Which is Periodic Breathing?
Choose the Correct Image
Opioids
13
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
A
50-70 sec
1
Thomas, et. al. Curr. Opin Pulm Med. 2005
B
20-40 sec
14
Periodic Breathing
Howwaxing
are treatments
the same?
• Characteristics:
and waning
breathing pattern
- Optimize treatment for primary cause and monitor
• Length is based
on disease process causing the
- They are all central in origin so need ventilation
breathing pattern
- They can coexist in a patient
– Longer events
forsometimes
patients mimic
in heart
failure
(picture A)
- A can
B and
vice 1versa
─ 50-70 second events of CSR then followed by normal
How(waxing
are the and
different?
respiration
waning of respiration) in patients
1
with heart
failure
- Must
protect
against over-ventilation in A.
– Shorter events in those at altitude/neurological
disorders/renal failure1 (picture B)
─ 20 – 40 seconds on length1
A
50-70 sec
B
20-40 sec
15
1
Thomas, et. al. Curr. Opin Pulm Med. 2005
Why do central apneas occur?
Upper airway compromise
Respiratory Control Issues
Involuntary/Autonomic
Control
17
PAP Therapy: Decision Making Tree
OSA
Drive to breathe is OK
Try to breathe but can’t
get enough in
Fall asleep, airway
becomes unstable,
apnea occurs, wake up,
oxygen drops, CO2
increases, fall asleep,
do it all again
What would this
look like on a PSG?
HST?
Therapy download?
Hypoventilation
Drive to breathe is
inadequate to meet
metabolic needs
CSA
Central Events
Don’t breathe at all or
pattern is mixed up
Impaired Gas Exchange
Oxygen drops/Carbon
Dioxide rises.
Inadequate ventilation
May or may not arouse
Oxygen drops/CO2 rises
but not as much as OSA
Sleep is fragmented
What would this
look like on a PSG?
What would this
look like on a PSG?
HST?
HST?
Therapy download?
Therapy download?
18
What do you see on the PSG?
O
S
A
Note square wave pattern of OSA recovery breathing. Different from CSR.
Oximetry patterns.
OSA
Normal
CSA
19
Triangular
Paradoxical
Central or obstructive hypopnea? Likely response to CPAP?
20
PAP Therapy: Decision Making Tree
OSA
Hypoventilation
CSA
Obstructive Events
Try to breathe but can’t
get enough in
Impaired Gas Exchange
Oxygen drops/Carbon
Dioxide rises
Central Events
Don’t breathe at all or
pattern is mixed up
What would this
look like on a PSG?
What would this
look like on a PSG?
HST?
HST?
Therapy download?
Therapy download?
What would this
look like on a PSG?
HST?
Therapy download?
21
Hypoventilation
would look like
THIS!
flow
PAP
Volume and flow change slowly over time. With ASV,
target will gradually
lower and SV algorithms deliver CPAP pressure only
22
AVAPs Algorithm
< 1 cmH2O / min
increase
IPAP Setting
Pressure
Desired Volume
Volume
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.
23
PAP Therapy: Decision Making Tree
OSA
Hypoventilation
CSA
Obstructive Events
Try to breathe but can’t
get enough in
Impaired Gas Exchange
Oxygen drops/Carbon
Dioxide rises
Inadequate ventilation
Central Events
Don’t breathe at all or
pattern is mixed up
What would this
look like on a PSG?
What would this
look like on a PSG?
HST?
HST?
Therapy download?
Therapy download?
What would this
look like on a PSG?
HST?
Therapy download?
24
Which is Periodic Breathing?
Choose the Correct Image
Opioids
25
PAP Therapy: Decision Making Tree
OSA
Hypoventilation
CSA
Obstructive Events
Try to breathe but can’t
get enough in
Impaired Gas Exchange
Oxygen drops/Carbon
Dioxide rises.
Inadequate ventilation
Central Events
Don’t breathe at all or
pattern is mixed up
What might cause
this type of event?
What might cause
this type of events?
What might cause
this type of events?
26
Complex Sleep Apnea Components
OSA
Central SDB
Obstructive apneas
Obstructive hypopneas
Noninvasive Ventilation
Periodic Breathing
CSR
CPAP
APAP
BiLevel
Auto Servo
Ventilation
27
Hypoventilation
Central Apnea
Central Hypopnea
Volume Assured Pressure
Support with Rate
PAP Therapy: Decision Making Tree
OSA
Hypoventilation
Obstructive Events
Open the Airway
Impaired Gas Exchange
Ventilate
CPAP
Volume
Assured
Pressure
Support w/Rate
APAP
Bi-level
CSA
Central Events
Stabilize Breathing Pattern
Auto Servo
Ventilation
28
OSA
Periodic
Breathing
The
Bucket
Theory
Let’s talk about breathing during
sleep
Opioid
CSA
Trauma
CSA
29
BiPAP autoSV Advanced
Theory ofto
Operation
Algorithms
match the pathologies
Servo Ventilation Algorithm
• CPAP
PAP Therapy for
Patients with OSA
─ One level of pressure on inspiration and exhalation
─ Device may have the option to provide pressure relief in
early exhalation
• Auto titration therapy
cmH20
CPAP
─ Device pressure is adjusted based on airway dynamics and
device algorithm
Auto CPAP
cmH20
31
PAP Therapy for Patients with OSA/SDB
• Bi-level therapy
Flow pattern could look different depending
on position and spontaneous vs machine
breath. Why?
─ One level of pressure on inspiration and lower level of
HowPS
would
graphic
look
for AVAPS?
pressure on expiration.
the this
same
every
breath
Bi-Level
cmH20
• Auto Servo Ventilation
─ Device pressure is adjusted based on airway dynamics,
patient respiratory effort and flow and device algorithm. PS
varies according to need.
Auto SV
cmH20
32
PAP Therapy for Patients with CSR
More about Cheyne-Stokes Respiration
CO2 waxing and waning with under and over ventilation
Airflow
Pressure
Support
CO2 Stable , Breathing pattern stable,
Patient breathes on own with normal variability
Patient
Airflow
33
What therapy would you need for each breathing
pattern shown?
Most patients
will bring a
unique mix of
breathing
patterns!
34
Upper airway compromise
Respiratory Control Issues
Involuntary/Autonomic
Control
35
Complicated
The Complex
X 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.
36
What do you see?
37
What do you see?
AM060606
38
What do you see?
Proportionate changes in flow and effort.
Likely central in nature
39
What do you see?
AM060606
40
41
What do you see?
O
S
A
Note square wave pattern of OSA recovery breathing. Different from CSR.
Note difference in oximetry pattern.
OSA
Normal
CSA
42
Periodic breathing (CSR)
Polysomnography
Oximetry
REM Sleep
43
Triangular
Paradoxical
Central or obstructive hypopnea? Likely response to CPAP?
44
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
46
Advanced technology and YOU
The perfect combination!
AUTO EPAP
SV algorithm works ‘on top’ of
Auto EPAP
How do you think the patient’s
physiology will change during the first
weeks of ASV use?
47
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
Pearls
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!
49
In contrast to
uncomplicated OSA
patients titrated on
CPAP, the titration
doesn’t END on the
titration night. It is just
the beginning!
50