Obstructive Sleep ApneaMedical Treatment

including nPAP

A. Valipour, MD, FCCPDepartment of Respiratory and Critical Care

MedicineOtto-Wagner-HospitalVienna

• Prevalence: ~2-4% of population• Risk Factors:

• Obesity • Male Gender• Anatomic Risk Factors

• Symptoms: • Excessive Sleepiness• Snoring/Apneas/Choking• Cognitive Dysfunction/Depression

• Cardiovascular and metabolic morbidity and mortality

Obstructive Sleep Apnea: Fact Sheet

OSA: Medical Treatment

• Weight Loss• Positional Therapy• Drugs• Nasal dilators• nPAP• Alternatives?

Peppard PE, JAMA 2000

10% weight gain predicts 32% increase

in AHI

10% weight loss predicts 26% decrease

in AHI

Peppard PE, JAMA 2000

Berger G, Eur Respir J 2009

• 160 untreated Patients with Sleep Apnea • Age 50 ± 11yr• BMI 29 ± 5 kg/m2

• AHI 23 ± 22/hr

• Follow-Up Polysomnographic Recordings (5 ± 3 yrs)

Berger G, Eur Respir J 2009

Baseline vs. Follow-Up

15% Improvement

46% Stable

39% Deterioriation

Berger G, Eur Respir J 2009

Δ BMI 1kg/m2/yr↓

Δ AHI 5/hr

Positional therapy can yield moderate reductions in AHI but is clearly inferior to CPAP and long term compliance is poor.

Predictors of response: young age, lower AHI, less obese

Treatment: Positional Therapy

ERS Task Force „Non-CPAP therapies in Sleep Apnoea“, ERJ in press 2010

Antidepressants → suppression of REM sleep → increasing airway toneAcetazolamide → metabolic acidosis → resp. drive ↑Theophylline → respiratory drive ↑Doxapram → respiratory drive ↑

NO EVIDENCE THAT ANY DRUG IS LIKELY TO BENEFIT IN PATIENTS WITH OSA

Treatment: Drugs

ERS Task Force „Non-CPAP therapies in Sleep Apnoea“, ERJ in press 2010

Principle: Nasal dilation → Nasal resistance ↓→ fraction of oral ventilation ↓

Evidence: No consistent effect → snoring → apneas → sleep architecture

Treatment: Nasal Dilators

ERS Task Force „Non-CPAP therapies in Sleep Apnoea“, ERJ in press 2010

Treatment: Positive Airway Pressure Therapy

Pneumatic Splint of Upper Airway

Positive Airway Pressure Therapy:

Schwab RJ, AJRCCM 1996

CPAP↓

„Normalization“ of

upper airway dimensions

Positive Airway Pressure Therapy:

Schwab RJ, AJRCCM 1996

Indications for CPAP treatment

• AHI > 30/hr regardless of symptoms

• AHI 5-30/hr with symptoms, e.g.

• Excessive daytime sleepiness

• Insomnia

• Impaired cognition

• Cardiovascular disease

Loube DI, Chest 1999

Cassel W, Eur Respir J 1996

Becker HF, Circulation 2003

Dernaika TA, J Clin Sleep Med 2009

Drager LF, Am J Respir Crit Care Med 2007

Marin J et al., Lancet 2005

CPAP-Treatment: Reduction in cardiovascular morbidity and

mortality

CPAP use in a clinical setting

• Compliance/Adherence

• Side effects

• Humidification

• Auto-CPAP

• Expiratory pressure relief

Pépin JL et al, AJRCCM 1999

Kingshott RN, AJRCCM 2000

McArdle N et al, AJRCCM 1999

Regular use within first three months predicts long-term use

Sucena M, Eur Respir J 2006

Gay P, Sleep 2006

Up to 30% refuse or stop CPAP

therapy due to side effects

Mask problems

Nasal intolerance

Noise of the machine

Claustrophobia

CPAP: Side effects

Massie CA, Chest 1999

Potential strategies aimed at improving compliance and

decreasing side effects• Education and training

• Local therapy (Nose, Full Face Mask,…..)

• Humidification

• Auto-CPAP

• Expiratory Pressure Relief

Massie CA, CHEST 1999

Nussbaumer Y, Chest 2006

86% preferred Auto-CPAP over fixed CPAP

Ayas NT, SLEEP 2004;27:249-53.

CPAP vs. Auto-CPAP: no change in hours of use

Patruno V, Chest 2007

CPAP: Expiratory pressure relief

Nilius G, Chest 2006

No difference in compliance

after 7 weeks of treatment

EPR-PAP

Less side effects to the upper airways

↓ Need for humidification ↓

Potential benefit for Expiratory Pressure Relief PAP

Valipour A, ERS 2008

EPR-PAP

Pts. with symptomatic OSA requiring CPAP

Need for humidification?

CPAP

Need for humidification?

24 months 24 months

Matching: age, sex, BMI, OSA severity, sleepiness, CPAP pressure

Retrospective review of medical and insurance reports

3 sleep labs

Valipour A, ERS 2008

05

101520253035

CPAP EPR-PAP

% patients with humidifier prescription

p = 0.02

Valipour A, ERS 2008

37% reduction in humidifier prescription

with EPR-PAP

Alternatives to treat OSA with CPAP?

• High flow transnasal insufflation

(TNI)

• Expiratory nasal valves

• „Didgeridoo“

10L/min - 20L/minHigh Flow

Insufflation

„High Flow“ Transnasal Insufflation (TNI)

TNI creates positive pharyngeal pressure

McGinley BM, Am J Respir Crit Care Med 2007

McGinley BM, Am J Respir Crit Care Med 2007

Responders:

Upper Airway Resistance Syndrome

Sleep-Hypopnea-SyndromeMild OSAS

Nilius G, Chest 2009

Expiratory Nasal Valves

Nasal valve treatment:Expiratory resistance creates positive upper

airway pressure

Colrain IM, J Clin Sleep Med 2008

1. Weight reduction: first line

treatment

2. Drugs inefficient

3. Nasal dilators inefficient

Conclusions

1. CPAP: Gold standard treatment

2. Side-Effects:

Humidification: Auto-CPAP, EPR-PAP

3. TNI, Nasal Valves → mild OSA

Conclusions

Aim: Keep the upper airway open

Thank you for your attention

Positive airway pressure alternatives?

Puhan MA, British Medical Journal 2006

Puhan MA, British Medical Journal 2006

• Obesity (Visceral Fat)

• Male Gender

• Menopause

• Age

OSA: Clinical Risk Factors

Pathophysiology: mechanical upper airway obstructionPharygeal pressure < Atmospheric Pressure

Flow

SaO2

Thorax

Abdomen

Apnea Apnea

OSA: Polygraphic Recording

OSA: Pathophysiological Consequences

• Repetitive Hypoxia

• Intrathoracic Pressure Swings

• Sleep Fragmentation

• Hypersomnolence/Insomnia• Fatigue/Depression

• Traffic accidents/Work accidents

• Art. Hypertension• Arrythmias• Myocardial infarction, Stroke• Metabolic Consequences

OSA: Clinical Consequences

Nilius G, Chest 2006

Ayas NT, SLEEP 2004;27:249-53.

Auto-CPAP: Reduction in mean therapeutic pressure

Ayas NT, SLEEP 2004;27:249-53.

CPAP vs. Auto-CPAP: no difference in AHI

Patruno V, Chest 2007

Mador MJ, CHEST 2005

No significant difference in complianceNo significant difference in symptoms (ESS)

Solutions ?

Problems Noise and bulk Nasal intolerance

Mask related problems

Technologic improvement

Limitation of the leaks around the

mask

Nasal decongestants

Full Face Mask

Warm humidifier +++

Limitation of mouth leaks (mouth strap)

Good education

Adapted mask

Technologic improvement

Trained technician

Modified from Levy P, ERS Course 2005

Auto-CPAPEPR-PAP

Young T, AJRCCM 2002

Prevalence of OSA

Lee RWW, Sleep 2009

• Retrognathia

• Neck Size

• Tongue Size

• Uvula

• Tonsills

OSA: Anatomic Risk Factors

Diagnosis: Recording of Sleep and Breathing

New England J Medicine 1999

Goncalvez SC, Chest 2007

Parish JM, Chest 2009

Punjabi NM, PLOS Med 2009