Adaptive Adaptive Servo-VentilationServo-Ventilation

CasesCasesGeoffrey S Gilmartin, MDGeoffrey S Gilmartin, MD

Beth Israel Deaconess Medical CenterBeth Israel Deaconess Medical Center

Harvard Medical SchoolHarvard Medical School

Boston, MABoston, MA

OutlineOutline

Case BasedCase Based Ventilatory Control During NREM SleepVentilatory Control During NREM Sleep

Conceptual frameworkConceptual framework Specific componentsSpecific components

Lessons LearnedLessons Learned CasesCases SnapshotsSnapshots LiteratureLiterature

ConclusionsConclusions

Case #1Case #1

SHSH37 yo male37 yo maleArnold Chiari malformation, spinal Arnold Chiari malformation, spinal

stenosis, syringomyeliastenosis, syringomyeliaShunt failure in cervical regionShunt failure in cervical regionHerniation, quadriplegia, PEG and TrachHerniation, quadriplegia, PEG and TrachSnoring converted to witnessed apneasSnoring converted to witnessed apneasEDS and extended sleep timesEDS and extended sleep times

Case #1Case #1

Previous PSGPrevious PSGFailed CPAP/BI-level titrationFailed CPAP/BI-level titrationResidual diseaseResidual disease

624 central and 121 obstructive events624 central and 121 obstructive events

CPAP=7, BI-level=11/7 with RDI-22CPAP=7, BI-level=11/7 with RDI-22Treated at home and intolerantTreated at home and intolerantCurrent treatment with O2 2 lpmCurrent treatment with O2 2 lpm

Referred for evaluationReferred for evaluation

Case #1Case #1

Case #1Case #1

Case #1Case #1

Case #1Case #1

Case #1Case #1

Sleep Disordered BreathingSleep Disordered Breathing

Obstructive Sleep ApneaObstructive Sleep ApneaCPAPCPAPCardiovascular, metabolic riskCardiovascular, metabolic risk

Central Sleep ApneaCentral Sleep ApneaCheyne-Stokes RespirationCheyne-Stokes RespirationComplex Sleep ApneaComplex Sleep ApneaMixed Sleep ApneaMixed Sleep Apnea

Cheyne Stokes RespirationCheyne Stokes Respiration

The SystemThe System

NREM

Loss of wakefulness drive

Ventilatory Pattern

Generator

Medulla (pH)

Carotid Body (PCO2, PO2)

Upper Motor Neuron

Lower Motor Neuron

Respiratory Muscle/Chest Wall

Adapted From: Malhotra, Berry and White, “Central Sleep Apnea”

CSDB-TreatmentCSDB-Treatment

Body Position-Body Position- Ventilatory Reserves/ObstructionVentilatory Reserves/Obstruction

Sleep Consolidation-Sleep Consolidation- Ventilatory Overshoot/Sleep Wake InstabilityVentilatory Overshoot/Sleep Wake Instability

Supplemental O2-Supplemental O2- Stabilize ChemoreceptorsStabilize Chemoreceptors

CPAP/BI-level Pressures-CPAP/BI-level Pressures- Plant GainPlant Gain

Stabilize Ventilation- “Adaptive Ventilation”Stabilize Ventilation- “Adaptive Ventilation” Stabilize Plant GainStabilize Plant Gain

Adaptive Servo-VentilationAdaptive Servo-Ventilation

Determine Target VentilationDetermine Target Ventilation Monitors recent average minute ventilation (ie.~3 min Monitors recent average minute ventilation (ie.~3 min

window)window) Calculates a target ventilation (ie. 90% of recent Calculates a target ventilation (ie. 90% of recent

average ventilation)average ventilation)

Ventilates to the TargetVentilates to the Target Algorithm monitors patient ventilation and compares it Algorithm monitors patient ventilation and compares it

to the target ventilationto the target ventilation Adjusts pressure support up or down as needed to Adjusts pressure support up or down as needed to

achieve targetachieve target Back-up rate when neededBack-up rate when needed

End Expiratory PressureEnd Expiratory Pressure

EEP = CPAP level EEP = CPAP level FixedFixed

May adjust to improve upper airway May adjust to improve upper airway obstructionobstruction

EEP: manually titrate like CPAP to hold airway patent

Time

Pressure (cm H20)

Pressure Support (PS)Pressure Support (PS)

Pressure support = Pressure support =

(Peak Inspiratory Pressure – End Expiratory Pressure)(Peak Inspiratory Pressure – End Expiratory Pressure)

Pressure support varies between limitsPressure support varies between limits minPSminPS maxPSmaxPS

Can vary the range Can vary the range Device determines the levelDevice determines the level

maxPS

Time

Pressure (cm H20) minPS

ResponseResponse

The device “automatically” adjusts the magnitude of The device “automatically” adjusts the magnitude of pressure support breath by breath to:pressure support breath by breath to:

Provide minimal support during hyperpnea or stable Provide minimal support during hyperpnea or stable breathingbreathing

Increase support during hypopnea or apnea Increase support during hypopnea or apnea Assumption is all is centralAssumption is all is central

Time

Pressure (cm H20)

Central apneaNormalbreathing effort

Cautions-HypoventilationCautions-Hypoventilation

Chronic hypoventilationChronic hypoventilationModerate to severe COPDModerate to severe COPDChronically elevated PCOChronically elevated PCO22 on ABG (> 45 on ABG (> 45

mm Hg)mm Hg) Restrictive thoracic or neuromuscular Restrictive thoracic or neuromuscular

diseasedisease

BaselineBaseline

Effort

Flow

SpO2

Central even, no effort

Desaturations after Central apneas

One CSR/CSA cycle, ~1min

Support When NeededSupport When Needed

Effort

Flow

SpO2

FG

Continued AdaptationContinued Adaptation

Response to remaining eventsResponse to remaining events

Effort

Flow

SpO2

FG

Stability?Stability?

Effort

Flow

SpO2

FG

Variable Input = Stability?Variable Input = Stability?

20012001

Adaptive Pressure Support Servo-Adaptive Pressure Support Servo-VentilationVentilation

Teschler H, et al.Teschler H, et al.AJRCCM, 164, 614-19, 2001AJRCCM, 164, 614-19, 2001

Patients with CHF and CSR (3%, >15/hr)Patients with CHF and CSR (3%, >15/hr)Acute prospective randomized crossoverAcute prospective randomized crossover5 sequential nights5 sequential nightsN=16N=16

Teschler, et al.Teschler, et al.

Teschler, et al.Teschler, et al.

Teschler, et al.Teschler, et al.

Teschler, et al.Teschler, et al.

Single night (acute) studySingle night (acute) studyDid randomize orderDid randomize orderCovers standard interventionsCovers standard interventionsASV performs well in this population, in ASV performs well in this population, in

the labthe labPCO2 results “reassuring”PCO2 results “reassuring”

Case #2Case #2

RARA67 yo male67 yo maleAsthmaAsthmaOSA-AHI=13, RDI=43, desats to 80%OSA-AHI=13, RDI=43, desats to 80%Failed CPAP/BIPAP Titration-AHI=14.7Failed CPAP/BIPAP Titration-AHI=14.7Adapt SV- EEP 5-7, PS 2-10Adapt SV- EEP 5-7, PS 2-10PerfectionPerfection

Recent DataRecent Data

Adaptive Servoventilation Versus Adaptive Servoventilation Versus Noninvasive Positive Pressure Noninvasive Positive Pressure

Ventilation for Central, Mixed And Ventilation for Central, Mixed And Complex Sleep Apnea SyndromesComplex Sleep Apnea Syndromes

Morgenthaler T, et al.Morgenthaler T, et al. Sleep, 30(4), 2007Sleep, 30(4), 2007 Multicenter, prospective randomized crossover Multicenter, prospective randomized crossover

designdesign

Morgenthaler et al.Morgenthaler et al.

Morgenthaler, et al.Morgenthaler, et al. DEFINITITIONSDEFINITITIONS

CSA-CSRCSA-CSR CAI >5 events/hrCAI >5 events/hr CAI/AHI >50%CAI/AHI >50% CSR patternCSR pattern

SA-MixedSA-Mixed AHI >5AHI >5 >50% mixed apneas>50% mixed apneas

Complex SASComplex SAS AHI >5 (majority obstructive)AHI >5 (majority obstructive) CAI >5 or CSR during titration at best CPAPCAI >5 or CSR during titration at best CPAP

Morgenthaler et al.Morgenthaler et al.

Morgenthaler, et al.Morgenthaler, et al.

Morgenthaler, et al.Morgenthaler, et al.

Morgenthaler et. al.Morgenthaler et. al.

Small studySmall studyDefinitions standard and importantDefinitions standard and importantBi-level alone poorBi-level alone poorExclusion criteria-Exclusion criteria-

CPAP >10CPAP >10HypoventilationHypoventilationUnstable CHFUnstable CHF

Beneficial, ? superiorBeneficial, ? superior

Case #3Case #3

CHCH83 yo male83 yo maleCAD-IMI, EF=55%, CRICAD-IMI, EF=55%, CRIOSA-AHI=82.5, Sat Nadir 88%OSA-AHI=82.5, Sat Nadir 88%Failed BIPAP 13/8 with 2 lpm O2Failed BIPAP 13/8 with 2 lpm O2Concern for central sleep apneaConcern for central sleep apneaASV titration-EEP 5-8, PS-3-10ASV titration-EEP 5-8, PS-3-10DisasterDisaster

Long TermLong Term

Compliance with and effectiveness of Compliance with and effectiveness of adaptive servo-ventilation versus CPAP adaptive servo-ventilation versus CPAP

in the treatment of Cheyne-Stokes in the treatment of Cheyne-Stokes respiration in heart failure over a six respiration in heart failure over a six

month periodmonth period

Philippe C, et. al.Philippe C, et. al. Heart 92, 337-42, 2006Heart 92, 337-42, 2006 Randomized, prospective trial (CSR)Randomized, prospective trial (CSR)

BackgroundBackground

CPAPCPAP Improves CSRImproves CSRDecreases SNADecreases SNA Improves ejection fractionImproves ejection fraction Improved combined mortality-cardiac Improved combined mortality-cardiac

transplantation ratestransplantation ratesBut, incomplete “in-lab” response But, incomplete “in-lab” response Relative benefit over time?Relative benefit over time?

Philippe, et al.Philippe, et al.

Subjects-Subjects- N=25N=25 18-80 yo18-80 yo Stable CHF (EF <45%), newly diagnosed CSRStable CHF (EF <45%), newly diagnosed CSR AHI >15, >80% centralAHI >15, >80% central

Design-Design- Randomized to Randomized to

Best CPAP (mean=8) or Best CPAP (mean=8) or ASV-Default settingsASV-Default settings

Philippe, et al.Philippe, et al.

Philippe, et al.Philippe, et al.

Philippe, et al.Philippe, et al.

ESS ESS Non-significant Non-significant

decreasedecrease

MWTMWT Non-significant Non-significant

increaseincrease

QOLQOL ImprovedImproved Greater in ASVGreater in ASV

Philippe, et al.Philippe, et al.

Philippe, et al.Philippe, et al.

Patients with CSR and symptomatic CHFPatients with CSR and symptomatic CHFReasonable compliance (> with ASV)Reasonable compliance (> with ASV) Improvement inImprovement in

CSR severityCSR severityQOL (greater in ASV)QOL (greater in ASV)EF (ASV only)EF (ASV only)

Hemodynamic toleranceHemodynamic tolerance

Case #4Case #4

DBDB79 yo male79 yo maleA-Fib, HTN, Spinal Stenosis, P-veraA-Fib, HTN, Spinal Stenosis, P-veraSleep Apnea-AHI=42.1, Nadir-80%Sleep Apnea-AHI=42.1, Nadir-80%CPAP poorly toleratedCPAP poorly toleratedAdapt Titration EEP 5-8, PS 3-10Adapt Titration EEP 5-8, PS 3-10Synchrony?Synchrony?

Very Recent DataVery Recent Data

Effect of Flow-Triggered Adaptive Effect of Flow-Triggered Adaptive Servo-Ventilation Compared with CPAP Servo-Ventilation Compared with CPAP in Patients with Chronic Heart Failure in Patients with Chronic Heart Failure

with Coexisting OSA and Cheyne-with Coexisting OSA and Cheyne-Stokes RespirationStokes Respiration

Kasai T, et. al.Kasai T, et. al. Circ Heart Fail. 2010:3:140-148Circ Heart Fail. 2010:3:140-148 Randomized, prospective trial Randomized, prospective trial 31 Patients31 Patients

Kasai et alKasai et al

Stable EF <50%Stable EF <50% Stable Class >/= II Heart FailureStable Class >/= II Heart Failure AHI >15AHI >15

Obstructive AHI >5Obstructive AHI >5 Cheyne-Stokes RespirationCheyne-Stokes Respiration

Not previously treatedNot previously treated Randomized to (titration) Randomized to (titration)

CPAP (4-12)CPAP (4-12) HEART PAP (flow-triggered ASV)HEART PAP (flow-triggered ASV)

Kasai et alKasai et al

Kasai et alKasai et al

Kasai et alKasai et al

Kasai et alKasai et al

ASV-TreatmentASV-Treatment

We knowWe knowPhysiologyPhysiologyPatientsPatientsLiteratureLiterature

In-labIn-labTitration process-what to controlTitration process-what to controlWhen to abandonWhen to abandonIf effective in lab, hope for long termIf effective in lab, hope for long term