Dr. Fulsen BOZKUŞ Akdeniz University Medical School

1. Effect of Upper Airway Location, Identified by Flextupe Reflectometry, on CPAP Pressure in Obstructive Sleep Apne Syndrome Patients Dr.Fulsen BOZKUŞ Akdeniz University Medical School

2. Obstructive Sleep Apne Syndrome It is a syndrome characterized by repeated upper airway obstruction and frequently accompanied by decrease in oxygen saturation.

3. OSAS PREVALENCE • ~% 2-4

4. Results of OSAS • Cardiovascular • Pulmonaryresults • Neurologycalresults • Psychiatricresults • Endocrynologicalresults • Nephrologycalresults • Gastrointestinalresults • Hematologycalresults • Socioeconomicresults • Mortality • Other

5. A DISEASE THAT SHOULD ABSOLUTELY BE TREATED

7. OSAS Pathophysiology • The airway wall is drawn inside with the negative intraluminal pressure composed during inspiration and decrease in oropharengeal muscle tonus.

8. OSAS Pathophysiology • Oclusiondevelopandapneaoccurviatheprogresiveincrease of airwayresistance.

9. OSAS Pathophysiology • It is thoughtthatcontinuouspositivepressureappliedtoupperairway can resolvethatoclusion.

10. CPAP Treatment • Sullivan et. al, gavecontinuouspressuretoupperairwaywith a nasal mask andinhibitedpharynxwallcollapsandsoapnea.

12. Upperairwayobstructionlocations in OSAS • Retropalathal • Retrolingual • Mix

13. Flextube reflectometry (Rhinosleep) • It is a technique that objective, done during sleep,easy to do, easy to tolerate,can show obstruction location and/or locations at the same time.

14. Rinosleep equipment anterior (left) and posterior appearance (rigth)

15. Rinosleep equipment lateral, miniprobe (left lower) and pump used in rinoflex tube attachment (left upper)

16. Marking of nasal cavity length in Flextube reflectometry Rhinoflex tube “0” point should be placed ritghly, uvula length marked and tube placed

17. Rinosleep study principle.

18. AIM • To determine if there is an effect of upper airway location, identified by flextupe reflectometry, on CPAP pressure in obstructive sleep apne syndrome patients or not.

19. Material - Method • July 2005 – December 2007 • AUMS ChestMedicine – ENT clinics • Patientthat OSAS wasdiagnosedand CPAP is indicated, wereincluded. • Retrospectiveandprospective

20. Material - Method • Questionnaireforpatientandfriend • Epworthslepinessscale > 12 PSG • AHİ>30 and AHİ 5-30 withday time slepiness CPAP titrasyonu • Upperairwayobstructionlocation flekstubereflectometry

21. Material - Method • Obstructionnumberandobstructionlocations: • Retropalathal (0-4 cm) • Retrolingual (4-9 cm) • Mix

22. VFO determined with rinosleep

23. DKO determined with rinosleep

24. mix obstruction determined with rinosleep

25. Material - Method • Exclusioncriterias • Polysomnographyandrhinosleeprecordstechnicallyinadequatepatients • >3 monthsbetweenpolysomnographyandrhinosleep

26. Material - Method • AnyothertreatmentotherthancorrectiveobstrucitonsurgeryappliedbetweenPolysomnographyandrhinosleep • RemarkableweigthdifferencebetweenPolysomnographyandrhinosleep

27. Material - Method • Patientswith COPD (OverlapSyndrome), chestwalldeformity, airwayobstructionandparanchymallungdisease • Psychiatricproblemsand/orsedativedrugusage

28. Material - Method • Age • Sex • BMI (kg/m2) • NeckCircumference • EpworthSlepynessScale • AHI • Obstructionlocationsandnumber, determinedbyRinosleep • CPAP titrationpressure

29. Findings • Total 102 patients • 40 patientsaccepted • 7 patientsexcluded • 33 patientsincluded • 28 (%84.84) male, 5 (%15.16) female

30. * Değişkenler ± SD olarak verilmiştir. Schedule 1. patients demographic data

31. WithFlextubereflektometry 9 patients (%27.2) retropalathal, 12 patients (%36.3) retrolingualand 12 patients (%36.3) mixobstruction. Therewas no significantcorrelationbetweenobstructionlocationsandobstructionnumber (p:0,886) (schedule 2.).

32. Schedule 2. patients obstruction locations and number determined by rinosleep

33. 40 35 30 25 20 15 10 5 0 VFO DKO MiX Figure .1. Obstruction locations determined by rinosleep.

34. Therewas no significantdifferencebetweenpatientsaccordingtoobstructionlocations in respecttoage, sex, BMI, AHI, EpwothsleepScale, neckcircumference

35. Therewas a statisticallysignificantcorrelationbetweenobstructionnumberdeterminedbyflextubereflektometryand AHI obtainedwith PSG . (pearsoncorrelationcoefficient, r:0.451, p:0.008) (figure 1.)

36. 80,00 60,00 40,00 Obstruction numbers determined by rinosleep 20,00 0,00 20,00 40,00 60,00 80,00 AHI determined by PSG o: intersections between AHİ determined by PSG and obstruction numbers determined by rinosleep Figure 2. Obstruction numbers determined by rinosleep and AHI determined by PSG.

37. Whenpatientsarecategorisedaccordingtoobstructionlocations; • CPAP pressure in Retrolingualgroupwasstatisticallyhigherthan in Retropalathalgroup, (p:0,003) • CPAP pressure in Mixobstructiongroupwasstatisticallyhigherthan in Retropalathalgroup (p:0,001)

38. * p:0.003 ⁿ p:0.001 Schedule 3. Obstruction locations and mean CPAP pressures.

39. 15 12,5 cpap pressure 10 7,5 5 TONGUE BASE GROUP MİX SOFT PALATE GROUP schedule.3. CPAP pressure distribution according to obstruction locations determined by rinosleep

40. Conclusion • Tongue base obstruction migth be one of the reasons that increase CPAP titration pressure in OSAS • In patients who can not tolarate CPAP with flekstube reflektometry we can determine obstruction location, and if it is retrolingual obstruction, we can plan treatment modalities ( radyofrequency, tongue base suspension,...) to the tongue base.