Complex Sleep Apnea:
Clinical Challenges
Brian J. Bohner, M.D.
Diplomate ABSM
Fellow AASM
CBTS
Sept 14, 2012
Complex Sleep Apnea
Clinical Challenges:
Objectives
Definition of Complex Sleep Apnea
Causes of Central Apnea Developing on CPAP
Therapy
Natural History
Diagnostic and Therapeutic Challenges
Case Study – T.Y.






54 Y.O. Male C/O:
1.
2.
3.
Daytime Sleepiness/Fatigue
5-10 Awakenings per Night
Snoring
1.
2.
3.
HTN
Lumbar Arthritis
No history or symptoms of CHF
PMH:
Medications:
1.
2.
3.
Celebrex
Metoprolol
No opiates
1.
Chronic nasal congestion


Wt = 199 lbs, (BMI = 27)
Moderate nasal congestion
ROS:
Exam:
ESS (Epworth Sleepiness Scale): 16
Baseline Polysomnogram
Baseline Polysomnogram
Polysomnogram Results:
Apnea Index = 21.3
Apnea + Hypopnea Index = 43.1
Total Sleep Time = 4.8 Hours
O2 Saturation Nadir = 84%
Trial of Automatic CPAP:
AHI 18. 22 min large leak.
CPAP Titration Study
CPAP Titration – Development
of Central Events
Complex Sleep Apnea:
Definition
Complex Sleep Apnea is a form of sleep
apnea in which central apneas persist or
emerge (CAI >5) during attempts to treat
obstructive events with nCPAP or
Bilevel PAP.
Patient Characteristics
1. > 90% are Male (ref 14)
2. BMI is slightly less than average OSA
patient (ref 16)
3. ? Higher incidence of ischemic heart
disease or CHF (ref 15)
4. Slight predominance in atrial fibrillation,
opiate use (ref 1 and 2)
5. ? Elevated nasal resistance (ref4)
Natural History of Complex
Apnea
• Prevalence of syndrome- 5.7 to 20%.
• In 78%- 92% of pts, CAs resolve within
months in CPAP adherent patients.
• Of pts without Com SA on initial CPAP
titration, 4% developed it on 3 mo f/u !!
•
Ref 1 and 2
Polysomnographic Characteristics
 May have evidence of central events on
baseline PSG (CAI >5)
(ref 1)
 Events more common in nREM sleep (ref 16)
 Elevated Arousal Index (ref 16)
 On F/U CPAP titration in 2-3 months, persistent CA
more likely if severe OSA or CSA >5 (ref 1)
Clinical Impact of nCPAP in
“Complex Apnea”
1. Residual or Worsening Symptoms
(Fatigue, EDS, Depression) Secondary to
Arousals/Disrupted Sleep
2. Higher Incidence of “CPAP Difficulty” (ref18)
3. ↑ Sympathetic Activity (ref 18)
Controls of Breathing: AWAKE
xxx
o
o
A.Behavioral
B. Metabolic
1. Chemoreceptors
a. Carotid Bodies
Y axis = pCO2
b. Medulla
Eupnea
CO2
Reserve
Apnea Threshold
Controls of Breathing - Sleep
1. Loss of Behavioral Control
Y axis = pCO2
Oo
oo
REM
nREM
Apnea Threshold
Apnea Threshold
2. Narrow CO2 Reserve in nREM
3. Hypoxia Further Reduces pCO2
4. Metabolic Acidosis Widens CO2 Reserve
CO2
CO2
Reserve
Reserve
Controls of Breathing During Sleep - CHF
ooo
1. Pulmonary Afferent Receptors
xxx
xxx
xxx
oo
2. Loop Gain
A. Increased Response to pCO2
B. Increased Lung to Peripheral
Chemoreceptor Circulation Time
Apnea Threshold
Controls of Breathing During Sleep
Effects of nCPAP/Bilevel PAP
1. Effect of Opening Airway - ↑ Minute
Ventilation (Increases plant gain)
2. Fragmented Sleep with Arousal –
(discomfort/ elevated nasal resistance)
3. PAP induced distention of stretch
receptors (Hering Breuer inflation reflex)
CO2
Reserve
Apnea Threshold
Diagnostic Challenges
1. Increasing number of patients not
undergoing CPAP titration
2. Autotitrating PAP devices vary in ability to
warn clinician of emerging central apnea
3. Failure to diagnose Complex Apnea may lead
to poor compliance and abandonment of PAP
therapy.
4. Overtitration may result in inappropriate dx.
Waveform Report
Therapy for Complex Apnea
1. Adaptive Servo Ventilation
2. nCPAP
Close F/U, permissive flow limitation/ additional dead
space
3. Supplemental 02
4. Medications benzodiazepines/ acetazolamide
Adaptive Servo Ventilation (ASV)
 Airway Pressure Device devised for Treatment of
CSA/CSR as well as Complex Apnea
 Automatic Pressure Support (Dynamically
Calculated) to result in Consistent Tidal
Volume
 Automatic Backup Rate (Calculated)
 Multiple Studies show Effective Clinical
Results in Treating Complex Apnea
Respironics
BiPAP Auto SV
Responds to Peak Flow and Adjusts
Pressure Support Accordingly
Manufacturers Suggestion for Settings:
Set EPAP or EPAP min
Set PS 2-15
Set IPAP max = 25
Rate = auto
BiPAP Auto SV
Breath to Breath
Pressure Support
Backup
Breath
Stabilization of
Breathing
Res Med
♠ VPAP Adapt SV
♠ Algorithm Directed at Measuring “Baseline”
TV and Respiratory Rate
♠ Can Titrate for EPAP (EEP) or use “Default
Setting” of 5 cm
♠ IPAP Suggestions:
Set Min PS = 3 cm
Set Max PS = 10 cm
The VPAP Adapt SV Response
Adapt SV responds to apnea by increasing support
Airflow
APNEA
HYPOPNEA
VPAP Adapt SV
(ASV mode on)
(Apnea converted to a hypopnea & breathing quickly normalized by VPAP Adapt SV)
CSA/CSR Returns Without
Treatment
ASV mode turned off
Airflow
VPAP Adapt SV
Off
(CSA/CSR rapidly returns)
Comparison
•
•
•
•
•
VPAP Adapt ASV
(n=35)
Avg use
5.0
Change ESS
-2.5
% nights > 4 h
67
CMS compliant % 34
•
•
•
•
•
BIPAP Auto ASV
(n=41)
6.0
-4
73.5
51
• Reference 3
Patient T.Y. On ASV
Therapeutic Challenges
1.
Adaptive Servo Ventilation costly
2.
nCPAP may eventually be adequate therapy.
3.
Other therapies not well studied.
Conclusions/ Suggestions
Clinicians caring for all OSA pts need proper
training/ education given prevalence and
natural history of Complex SA.
Difficult to predict patients who will develop
the syndrome.
Prevalence of the syndrome highlights
importance of CPAP titration study in OSA
patients.
Conclusions/ Suggestions (cont)
• Treatment decision generally pertains to ?
ASV vs close f/u on CPAP
• Insurance carriers may impact on these
decisions
• Suggest confirming emergent CAs prior to
ASV titration
• Consider 02 and pharmacologic agents
• Need to consider best therapy for pt, but
sensitive to costs (CPAP titration/ ASV)
For More Info: www.smaminfo.com
References
1. Javaheri The prevalence and Natural History of Complex Sleep Apnea
JCSM No 3, 2009 205-211
2. Hoffman The Appearance of Central Sleep Apnea after Treatment of Obstructive Sleep Apnea
Chest Aug 2012 517-522
3. Kuzniar Comparison of two servo ventilator devices in the treatment of complex sleep apnea
Sleep Medicine (2011) 2010.09.017
4. Nakazaki Continuous positive airway pressure intolerance associated with elevated nasal
resistance is a possible mechanism of complex sleep apnea Sleep Breath (2012) 16:747-752
References
5
Efficacy of adaptive servoventilation in treatment of complex and central sleep apnea syndromes.
Chest. 2007 Dec; 132 (6): 1839-1846.
PMID: 18079219 [PubMed – indexed for MEDLINE]
6.
CPAP should be used for central sleep apnea in congestive heart failure patients.
J Clin Sleep Med. 2006 Oct; 15;2 (4): 394-398.
PMID: 17557465 [PubMed – indexed for MEDLINE]
7.
Brown LK, Casey KR.
Complex sleep apnea: the hedgehog and the fox.
Curr Opin Pulm Med. 2007 Nov; 13 (6): 473-478.
PMID: 17901751 [PubMed – indexed for MEDLINE]
8.
The significance and outcome of continuous positive airway pressure-related central sleep apnea during
split-night sleep studies.
Chest. 2007 Jul; 132 (1): 81-87. Epub 2007 May 2.
PMID: 17475636 [PubMed – indexed for MEDLINE]
References
9. Chest. 2007 Feb; 131 (2): 595-607. Review
PMID: 17296668 [PubMed – indexed for MEDLINE]
10. Recognition and management of complex sleep-disordered breathing.
Curr Opin Pulm Med. 2005 Nov; 11 (6): 485-493. Review.
PMID: 16217173 [PubMed – indexed for MEDLINE]
11. Javaheri S.
Acetazolamide improves central sleep apnea in heart failure: a double-blind, prospective study.
Am J Respir Crit Care Med. 2006 Jan 15; 173 (2): 234-237. Epub 2005 Oct 20.
PMID: 16239622 [PubMed – indexed for MEDLINE]
12. Kuzniar TJ, Golbin JM, Morgenthaler TI.
Moving beyond empiric continuous positive airway pressure (CPAP) trials for central sleep apnea: a
multi-modality titration study.
Sleep Breath. 2007 Dec; 11(4): 259-266.
PMID: 17541664 [PubMed – in process]
References
13.
Kuzniar TJ, Pusalavidyasagar S, Gay PC, Morgenthaler TI.
Natural course of complex sleep apnea – a retrospective study.
Sleep Breath. 2007 Sept 15; (Epub ahead of print)
PMID: 17874254 [PubMed – as supplied by publisher]
14 .
Lehman S, Antic NA, Thompson C, Catcheside PG, Mercer J, McEvoy RD.
Central sleep apnea on commencement of continuous positive airway pressure in patients with a
primary diagnosis of obstructive sleep apnea-hypopnea.
J Clin Sleep Med. 2007 Aug 15; 3 (5): 462-466.
PMID: 17803008 [PubMed – indexed for MEDLINE]
15.
Morgenthaler TI, Gay PC, Gordon N, Brown LK.
Adaptive servoventilation versus noninvasive positive pressure ventilation for central, mixed, and
complex sleep apnea syndromes.
Sleep. 2007 Apr 1; 30 (4): 468-475.
PMID: 17520791 [PubMed – indexed for MEDLINE]
16
Morgenthaler TI, Kagramanov V, Hanak V, Decker PA.
Complex sleep apnea syndrome: is it a unique clinical syndrome?
Sleep. 2006 Sept; 7 (6): 474-479. Epub 2006 Aug 23.
PMID: 16931153 [PubMed – indexed for MEDLINE]
References
17.
Papacostas SS, Myrianthopoulou P, Dietis A, Papathanasiou ES.
Induction of central-type sleep apnea by vagus nerve stimulation.
Manual
CPAP/ASV Titration Effective Date:
Electromyogr Clin Neurophysio.
2007 Jan-Feb;
47 (1): 61-63.
Supercedes: All Others
Procedure
PMID: 17375884 [PubMedSection
– indexed for MEDLINE]
Standard Operating Procedure
ADULT PSG
Chapter 4
Page 1 of 1
18.
19.
20.
Pusalavidyasagar SS, Olson
EJ, Gay PC, Morgenthaler TI.
DEFINITION- Titration with Adaptive Servo Ventilation (ASV) is performed in
patients with complex sleep apnea. This includes patients with emergent central apneas or
Cheyne
Stokes Breathing
(CSB) on CPAP therapy.
Treatment of complex sleep
apnea
syndrome:
a retrospective comparative review.
PURPOSE- This titration protocol is designed a.) CONFIRM the diagnosis in patients
suspected
of having complexEpub
apnea, when a2006
diagnosis has
not recently
Sleep Med. 2006 Sept; 7 (6):
474-479.
Aug
23.been confirmed by
CPAP titration study, and b.) provide specific guidelines for proceeding to ASV titration
based on response to CPAP titration.
PMID: 16931153 [PubMed – indexed for MEDLINE]
POLICIES- The initial portion of this titration study will be performed on CPAP to
assure that CPAP alone will not be an adequate treatment for the patient’s sleepdisordered breathing. During the CPAP portion of the study, attempts will be made to
adjust CPAP downward (to assure central apneas are not due to excessive CPAP
pressure), or upward (if obstructive events are actually present). In patients with
persistent central events or CSB, standard ASV titration will be conducted.
Thomas RJ.
Effect of added dead spacePROCEDURES
to positive airway pressure for treatment of complex sleep-disordered
I. Order/CMN
breathing.
a. An order or CMN must be accompanied with H&P and previous PSG/Titrations.
b. Hook up and preparation as per Adaptive Servo Ventilation (ASV) protocol. After
lights out, patient is provided CPAP at “starting pressure” (if not designated on
Sleep Med. 2005 Mar; 6 (2): 177-178.
order, begin at 5cm). Epub 2005 Jan 25.
Titration will be performed
first.
PMID: 15716223 [PubMedII. CPAP
–a. Ifindexed
for MEDLINE]
central apneas are confirmed (5 in 15 minutes), reduce CPAP in 2cm
increments, allowing 15 minutes at each setting.
b. If obstructive events are present, increase CPAP in 2cm increments, allowing 15
minutes at each setting.
c. If Cheyne Stokes breathing is confirmed, continue monitoring x 30 minutes to
document the breathing pattern, then change to ASV support.
d. If central apneas persist with reducing CPAP pressure to a level at which
obstructive events now occur (> 3 events in 15 minutes), change patient to ASV
support.
Wang D, Teichtahl H, Drummer O, Goodman C, Cherry G, Cunnington D, Kronborgl
Central sleep apnea in stable methadone maintenance treatment patients.
Chest. 2005 Sept; 128 (3): 1348-1356.
PMID: 16162728 [PubMed – indexed for MEDLINE]