Pamela Minkley RRT, RPSGT, CPFT

1. Different Types of Central Sleep ApneaFigure out what’s causing it and you’ll know how to treat it! Pamela Minkley RRT, RPSGT, CPFT Make Sleep a Priority March 2013

2. Goals and Objectives Describe the physiologies of complex breathing disorders associated with CSA Identify PSG respiratory patterns associated with CSA pathologies 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”

3. 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. Non-metabolic Metabolic Metabolic** Metabolic Metabolic Behavior Inactive Active Transitional Sleep* Stage 2 Slow Wave Sleep REM Sleep Regular Irregular Periodic Regular Irregular Regular Major Influence on breathing Rare Often Absent Absent Absent Frequent Pattern of breathing Decreased Present Mild Decrease Variable Mild Decrease Mod. Decrease Central Apneas/Hypopneas Phasic Phasic Phasic Phasic Paradoxical Phasic 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. Physiologic Changes in Respiratory Control with Sleep 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 PEARL Scoring criteria… Diagnostic criteria…. Reimbursement criteria….. May sometimes conflict with each other • 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

12. PSG pattern recognition for central respiratory events.

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

14. 20-40 sec Periodic Breathing A B 50-70 sec 1 Thomas, et. al. Curr. Opin Pulm Med. 2005 • 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

15. 20-40 sec Periodic Breathing 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. A B 50-70 sec • 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 1 Thomas, et. al. Curr. Opin Pulm Med. 2005

16. Why do central apneas occur?

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

18. PAP Therapy: Decision Making Tree OSA Hypoventilation CSA Drive to breathe is OK Try to breathe but can’t get enough in Drive to breathe is inadequate to meet metabolic needs Central Events Don’t breathe at all or pattern is mixed up Fall asleep, airway becomes unstable, apnea occurs, wake up, oxygen drops, CO2 increases, fall asleep, do it all again 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? 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?

19. 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

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

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

22. 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

23. 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.

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

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

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

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

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

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

30. BiPAP autoSV AdvancedTheory of OperationServo Ventilation Algorithm Algorithms to match the pathologies

31. CPAP Auto CPAP cmH20 cmH20 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

32. 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 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.

33. PAP Therapy for Patients with CSRMore 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 PatientAirflow

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

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

36. Complicated X The Complex Sleep Apnea Bucket List

37. What do you see?

38. What do you see? AM060606

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

40. What do you see? AM060606

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

43. Periodic breathing (CSR) Polysomnography Oximetry REM Sleep

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

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

47. 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?

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.”

49. 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! In contrast to uncomplicated OSA patients titrated on CPAP, the titration doesn’t END on the titration night. It is just the beginning!